Register Undergraduate Affiliates
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REGISTRATION FORM: UNDERGRADUATE AFFILIATES
Your Name: ___________________________ Date of Birth: __ __ ____
Male or Female (optional): M F Mr. Ms. Mrs. Dr. (optional)
Street Address, City, State, Zip: _________________________________
Phone:( ) ___ ____ Fax: ( ) ___ ____ email:______________________
Web site address: if you have one: _______________________________
US Citizen? yes ___ or Visa holder? yes ___
Undergraduate Degree(s), School, Year:
If Professionally Licensed Field(s), with State and number:
Specializations(s): (List all)
Will you buy and sell services through the National Architect? Yes__No__
Do you feel you will increase your value (as you define it) through active Affiliation? Yes __ No___
Name of your University/School:
Do you do Research? Yes __ No___
Interested in Potential Applied Research Topics/Projects?
Yes __ No__
Interested in Consultation outside Academic Responsibilities? Yes__No What Skills:
Hourly Rate Range:
Would you mentor undergraduate or graduate students we help place in internships? Yes __ No__
Please send your resume via email.
Please list three professional or academic references with full
Contact 1:(name, address, phone, email)
Contact 2:(name, address, phone, email)
Contact 3:(name, address, phone, email)
Why do you want to affiliate with the National Architect?
What will you bring to the National Architect which is unqiue?
What professional issues do you find most challenging, and really want to solve?
Annual Subscription Fee: (add to cart)
copyright, National Architect Corporation, 16 September, 2014
REGISTRATION FORM: DONOR AFFILIATES