CAS_ContactInfoForm

Email List Information Form
*( Indicates Required Field)**

* First Name:
Middle Name:
* Last Name:

*Email:
Web page URL:
Telephone:

Institution or Company Name:
Title:
Department:
To receive newlsetters & posters:
Address:

City/Town/Locality:
State/Province:
Zip Code/Postal Code:


*CHECK ONE:
UCB Undergraduate Student UCB Graduate Student UCB Faculty UCB Staff UCB Visiting Scholar or Post Doctoral Fellow Non-UCB Undergraduate Student	Non-UCB Graduate Student Non-UCB Faculty K-12 Teacher Community Organization / Government / Business / Media General Public

To help us in developing the Africanist community, please provide the following information:
Discipline/Major:
Country/Regional Interest(s):
Research Interest(s):
Overseas Experience:
Languages Spoken (especially African Languages):
If you are originally from Africa, which country?
We often get calls from organizations seeking speakers. Can we add you to our speaker's bureau based on your areas of specialty?	Yes