Participant Biographical Information
1.

Please enter the information indicated below.  This information will be used to create biographies that will be distributed to all participants.


First Name:
Middle Name:
Last Name:
Job Title:
Company Name:
Email Address:
emailaddress@xyz.com
Phone (Cell):
Phone (Home):
Phone (Work):
Primary Mailing Address 1:
Primary Mailing Address 2:
Primary Mailing City:
Primary Mailing State:
Primary Mailing Zip:
Secondary Mailing Address 1:
Secondary Mailing Address 2:
Secondary Mailing City:
Secondary Mailing State:
Secondary Mailing Zip:

2.
In which Arizona county do you primarily reside?
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
3.

Have you ever attended a statewide Town Hall?

If yes, please list those you have attended. 

Yes
No
  • Comment:

  • 500 characters left.
4.

Your education (where, when, degrees). 

 

350 characters left.
5.

List the CURRENT civic and cultural organizations in which you participate, including any offices held.

 

350 characters left.
6.

List the PAST civic and cultural organizations in which you have participated, including offices held. 

 

350 characters left.

The following questions will assist in grouping participants in a manner that best represents a diverse cross-section for each panel.

 
7.

Your gender.

Female
Male
Other
8.

Your ethnicity.

African American
Asian American, Pacific Islander
Caucasian
Hispanic/Latino
Native American/American Indian
Other
Unknown
9.

Your age group.

18 - 30
31 - 45
46 - 65
Over 65
10.

Your occupational categories (select all that apply).

Agriculture, Farming, Ranching
Arts & Entertainment
Attorney
Builder, Developer, Realtor
Business, General
Clergy, Faith-based Organization
Education
Environment, Conservation
Financial
Government/Public Official
Healthcare
Judiciary, Courts
Labor
Media, Comunications
Mining
Organization, nonprofit
Retired, Community Volunteer
State Legislature
Student
Utility
Other  
11.
Here are some of the questions, ideas and issues that I would like to see discussed at the statewide Town Hall on Criminal Justice in Arizona.
The discussion questions at the Town Hall will be drafted from participant submissions.
 

1000 characters left.