School or Organization Name

Contact Name

Position/Title

Email

Phone Number

Potential Event Dates (maximum 3; one per line)

Estimated Number of Participants

Estimated Number of Computers/Laptops available at Your Location

Is there a strong internet connection at Your Location?
 Yes No

Are you interested in local Information Technology (IT) Professionals participating in the event as Speakers?
 Yes No

How did you hear about our I.T. Awareness Events?