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Higher Ed Alliance - Member Representative Information Form
Help the NCWIT Higher Ed Team get to know you and your department better by completing the member representative information form. Information provided is helpful to us as we develop programs and activities, seek grant funding, and provide information to our funders. If you have any questions, please contact us at
highered@ncwit.org.
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* Indicates required question
Are you a new or existing NCWIT Member Representative?
New Member Rep
Existing Member Rep
What is your preferred honorific or title? [e.g., Dr., Mr., Mrs., Ms., Mx., Professor]
Your answer
What is your first name?
*
Your answer
What is your last name?
*
Your answer
What is the name of your current university, college, or organization?*
*
Your answer
What is your job title?
*
Your answer
Would you kindly provide a faculty/staff directory or LinkedIn URL?
Your answer
What email address should NCWIT use to communicate with you?
*
Your answer
What phone number should NCWIT use to communicate with you?
Your answer
What is your Street Address?
Your answer
What is your building and office number?
Your answer
City
Your answer
State
Your answer
Zip code
Your answer
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