Name *

First Name

Last Name

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number

Permanent/mobile number preferred. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.

(###)

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I am interested in serving as an advisor to a local chapter

Yes

I am interested in providing professional advice or being a mentor to undergraduates

Yes

Include career news in The Triad?

Yes, I would like to share my career news in The Triad.

Include family news in The Triad?

Yes, I would like to share my family news in The Triad.