Become a Member Connect 360 Membership Application Form Candidate InformationCandidate Name:(Required) First Last Referred By: Candidate Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Enter Email Confirm Email Employment BackgroundCommunity ActivitiesCandidate Questionnaire1. If selected, how do you feel you could contribute to the success of the Connect 360 initiative?2. Are you willing to give time, energy, and resources to support the mission of Connect 360? YES NO 3. Members stay connected to Connect 360 through meeting attendance, committee work, membership events, e-mail, and other communications. Do you have the time and resources to be an active member? YES NO 4. Are you comfortable soliciting others for membership and funding? YES NO If yes, please describe any experience in doing so:5. What do you believe are the two most significant problems facing society today?PhoneThis field is for validation purposes and should be left unchanged. Δ Mantracon Young AdultsIllinois WorknetThe Illinois Department of Employment Security (IDES)The 211- Offers helpIllinois Family Care Carbondale NaacpSouthern Illinois Unity CoalitionFind LawyersLand of Lincoln Legal Aid, Inc.
