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| *Your Name: |
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| *Email Address: |
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| Mailing Address: |
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| U.S. Zip Code: |
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| Display your Canadian or other zip code as it should appear when used (include appropriate spaces, dashes, etc.) |
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| Canadian/Other Zip Code: |
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| North American Phone Number: |
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| Other Phone Number: |
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| Fax Number: |
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| Please check the box that best describes your current occupation or fill in your current occupation in the "Other Occupation" box below. |
| *Your Occupation: |
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| If you are an Allied Practitoner, please note in the open box your area of specialization, e.g. lighting designer, urban planner, mechanical engineer, graphic designer, etc. |
| Allied Practitioner: |
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| If none of the listed occupations apply, please note your occupation in the open box. |
| Other Occupation: |
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| Please note your primary areas practice or research or note "Other" and identify your area of practice or research in the box below. |
| *Your Area of Practice or Research: |
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| Other Area: |
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| Please note design and human behavior issues that interest you (maximum of 3), especially as they relate to the collaborative connections you would like to make. If none apply, please check "Other" and provide a brief description of those issues (maximum of 3). |
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| *Design and Human Behavior Issues: |
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| Other Issues: |
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| Describe in the space below what you are looking for from a collaboration and any ideas you might have about a project or endeavor. |
| *Wanted: |
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| Be sure to describe in the space below what you can bring to a collaboration. Topics that you might want to outline are expertise, resources, or projects coming on line. |
| *Provided: |
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| Please note the time frame you are considering for this collaboration to begin. |
| *Your Time Frame: |
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| Please note the date that you would like your Collaboration Request posting to be removed from InformeDesign's Web site. |
| *Duration of Posting: |
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