Prefix: Mr. Mrs. Ms. Dr.

First Name:*

Middle Name:

Last Name:*

Suffix:

Title:*

Company Name:*

Business Address:*

Bus. Address 2:

City:*

State:* Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP:*

Business Phone:*

Business Fax:

Business Email:*

Business Website:

Home Address:

Home Address 2:

City:

State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP:

Home Phone:

Cell:

Home Email:

Preferred Email? Work Home

Referred By: Employer Recommendation Friend Co-Worker Family Member News Article Web Search In the Press Received Materials Web Site E-mail Event Colleague Arts & Business Council Newsletter Arts & Business Council Website Arts & Business Council Orientation Arts & Culture Organization Company Event Company Website/Intranet Other

If "Other"...

Please note: We request contact information for your supervisor in order to provide information about your contributions to the community through your involvement in the Technology Connectors. Contact is only done with your permission.

Supervisor Name:

Supervisor Title:

Supervisor Email:

Please select the types of arts organizations that might interest you. Select all that apply:

Arts Education
Children's Theater/Museums
Historic Preservation
Historic Sites/Museums
Horticultural
Libraries/Archives
Literary Arts
Media Arts
Performing Arts
Science Museums
Visual Arts
Zoological

Please select all geographic regions in which you are available to offer support:

Center City Philadelphia
Philadelphia County
Bucks County
Chester County
Delaware County
Montgomery County
Camden County
New Castle County

Please describe your experiences with nonprofit organizations (such as volunteer work, membership, board of directors):

Please select the areas in which you have expertise:

Website Development/Programming
Computer Upgrades
Website Design
Database Development/Design
Networking/LAN/WAN
Technology Needs Assessments
Wireless Networks/Technologies
Strategic Technology Planning
E-Commerce
Integration of New Technology
Software Selection
Software/Hardware Training
Hardware Selection
Internet Connectivity
Computer Maintenance
Desktop Support
Other: Specify
Vendor Selection/RFP Process
Experience with Mac OS

Do you consider your skills to be more "hands-on" or more consultative?

Hands-On
Consultative
Both

Please let us know of any other questions or comments:

Please read and check the boxes below to confirm you understand our application process:

I understand that in order to participate in Technology Connectors, I must participate in a training session.

Thank you for your interest in the Technology Connectors.