| First
Name* |
|
| Middle Initial |
|
| Last
Name* |
|
| Name You Prefer |
|
| Gender* |
Male
Female
|
| Age* |
18-25
26-35
36-45
46-55
56-65
66+ |
| Racial
or Ethnic Group* |
African American
American Indian
Asian or Asian American
Caucasian
Hispanic
Other |
| Birthdate* |
|
| Contact
Information |
| Email Address* |
|
| Daytime
Phone* |
|
| Evening Phone |
|
| Mobile
Phone |
|
| Street Address* |
|
| City* |
|
| State* |
|
| Zip* |
|
| Volunteer
Experience |
| Please
list you prior volunteer experience* |
|
| Please
list you prior experience with computer repair* |
|
| References |
| Reference
#1 |
|
| Name* |
|
| Phone Number
* |
|
| Reference
#2 |
|
| Name* |
|
| Phone Number
* |
|
| Reference
#3 |
|
| Name* |
|
| Phone Number
* |
|
|
|