General Advisory Committee Membership Form

	Date* (mm-dd-yyyy)

	Membership Status
	I'm new to the General Advisory Committee    I'm updating my information

	Salutation * (Mr. Mrs. Ms. Dr.)

	First Name*

	Last Name*

	Address*

	PO Box

	City*

	State*
	--Please Select--AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming

	Zip Code*

	e-Mail Address* NOTE: A personal or business e-mail address is required for all correspondences.

	Cell # (XXX-XXX-XXXX)

	Home # (XXX-XXX-XXXX)

	Company Name

	Job Title/Position

	Address

	PO Box

	City

	State
	--None--AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming

	Zip Code

	Work # & Extension (XXX-XXX-XXXX ext:XXXX)

	Work Cell #

	e-Mail Address NOTE: A personal or business e-mail address is required for all correspondences.

	Which shop are you affiliated with?* Choose one from the drop-down menu.
	--Please Select--Advanced Manufacturing & FabricationAutomotive Collision Repair & RefinishingAutomotive TechnologyBiotechnologyBusiness & EntrepreneurshipConstruction TechnologyCosmetologyCulinary ArtsDental AssistingDrafting & Design TechnologyElectricalElectronics & Engineering TechnologyEngineering & RoboticsHealth ServicesHeating, Ventilation, Air Conditioning & RefrigerationInformation TechnologyMultimedia CommunicationsPainting & Design TechnologyPlumbingVeterinary Assisting

	Are you BVT Alumni?*
	--Please Select--YesNo

	Which shop were you enrolled? Choose one from the drop-down menu.
	--None--Advanced Manufacturing & FabricationAutomotive Collision Repair & RefinishingAutomotive TechnologyBiotechnologyBusiness & EntrepreneurshipConstruction TechnologyCosmetologyCulinary ArtsDental AssistingDrafting & Design TechnologyElectricalElectronics & Engineering TechnologyEngineering & RoboticsHealth ServicesHeating, Ventilation, Air Conditioning & RefrigerationInformation TechnologyMultimedia CommunicationsPainting & Design TechnologyPlumbingVeterinary Assisting

	What year did you graduate?
	--None--2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970

	How are you affiliated with BVT? Check all that apply.
	General Advisory Committee Member    School Committee Member    Parent Advisory Committee (PAC)    State Representative    Parent/Guardian    Business Industry    Consultant    Community    Organized Labor    Registered Apprenticeship Program    Post Secondary Education    BVT Staff Member    BVT Student    Other, please specify

	To help us ensure our students see themselves and their communities represented in our General Advisory Committee, please consider answering the following optional questions. Note: your answers will not affect your acceptance to our General Advisory Committee.

	Gender
	--None--FemaleMaleOther

	Are you an individual with disabilities?
	--None--YesNo

	What is your ethnicity?
	Hispanic or Latino    American Indian or Alaska Native    Asian    Black or African American    Native Hawaiian or Pacific Islander    White