New Member Survey

Personal Information

Please fill in all fields.

Name 

Street 1

Street 2

City 

 

State 

 

Zip

Is this your home or work address?

 

 

 

Phone  (W)

 

(H)

 

 

Email 

Employer

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Involvement

Please check all that apply.

Would you be interested in helping out with any of the following
MATHCOUNTS
Engineers Week
Committees

What level of involvement would you like to have?

MATHCOUNTS

 

 

 

Planning the Activities

 

Grading papers on day of event

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Engineers Week

 

 

 

Planning activities

 

Helping with Mall exihibts

 

Helping with banquet

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

Other Committees

 

 

 

Community Leadership

 

Continuing Education

 

Membership Direction

 

Public Image

 

Public Policy

 

 

 

 

 

 

What do you hope to gain from PENC?

 

Professional Development

 

Networking

 

Community Involvment

 

Positive Image

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 
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Sponsorship

Please check all that apply.   

How did you find out about PENC?

 

 

Newspaper

 

Web Search

Current Member

 

Friend 

Mailing 

 

Other

 

 

Please enter any additional comments or questions you may have regarding PENC.

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Joel D. Smith, P.E.
Copyright © 2006 [PENC-CCC]. All rights reserved.
Revised:  December 2006