Page 3 - NAGC 67th Annual Convention Reimagined! Preliminary Program

4. Complimentary Membership Contact Information

Please provide contact and demographic information for the complimentary NAGC Premier membership below:
NAGC has a commitment to diversity. We will use the demographic information below to help us evaluate our progress in serving a diverse audience.
 Race-Ethnicity
 Asian
Name __________________________________________________________________________
 Black or African American
Title ____________________________________________________________________________  Hispanic or Latinix
 Mixed
Institute/Organization __________________________________________________  Native American/Alaskan Native
Address ______________________________________________________________  Pacific Islander
 White
City/State/Zip __________________________________________________________________  Other _______________
Phone _____________________________________(h) __________________________________(w)
 Year of Birth  Gender
Primary E-mail ___________________________________________________________________  After 2000  Female
Secondary E-mail __________________________________________________________________  1990-2000  Transgender Female
 1980-1989  Male
 I do not wish to have my name used for other mailing lists.  1970-1979  Transgender Male
 1960-1969  Gender Variant/Non-
 1950-1959 Conforming
 1940-1949  Prefer not to answer
 Before 1940  Other ____________

5. NAGC Electronic Access Only Membership Contact Information

Electronic Access Membership 1.
Please provide contact and demographic information for the complimentary NAGC Premier membership below:
NAGC has a commitment to diversity. We will use the demographic information below to help us evaluate our progress in serving a diverse audience.
Name Title Address E-mail Address Phone Term

 Race-Ethnicity  Gender  Year of Birth  I do not wish to have
 Asian  Female  After 2000 my name used for
 Black or African American Black  Transgender Female  1990-2000 other mailing lists.
 Hispanic or Latinix  Male  1980-1989
 Mixed  Transgender Male  1970-1979
 Native American/Alaskan Native  Gender Variant/Non-  1960-1969
 Pacific Islander Conforming  1950-1959
 White  Prefer not to answer  1940-1949
 Other _______________  Other ________________  Before 1940

Electronic Access Membership 2.
Please provide contact and demographic information for the complimentary NAGC Premier membership below:
NAGC has a commitment to diversity. We will use the demographic information below to help us evaluate our progress in serving a diverse audience.
Name Title Address E-mail Address Phone Term

 Race-Ethnicity  Gender  Year of Birth  I do not wish to have
 Asian  Female  After 2000 my name used for
 Black or African American Black  Transgender Female  1990-2000 other mailing lists.
 Hispanic or Latinix  Male  1980-1989
 Mixed  Transgender Male  1970-1979
 Native American/Alaskan Native  Gender Variant/Non-  1960-1969
 Pacific Islander Conforming  1950-1959
 White  Prefer not to answer  1940-1949
 Other ______________  Other ________________  Before 1940