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Membership
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Select Joint Memberships:
SWE Joint Membership
Select Special Interest Groups:
Energy
Environmental
ITTT
Process Improvement
Public Policy
Space
Women in Science and Engineering- WISE
Contact Information:
Prefix First Name M.I. Last Name Suffix
* *
Credentials:
Birth Date: mm/dd/yyyy
Phone #: *
Cell #:
Home Phone:
Fax #:
Email: *
Title:
Company:
Primary Address:
Street Address: *
Apt.#
City/State/Zip: * *
Country:
Province:  Non US and Canada only Override Verification?:
Secondary Address:
Street Address:
Apt.#:
City/State/Zip:
Country:
Province:  Non US and Canada only Override Verification?:
Additional Information
Educational Information
School Name (include full name of school, city, state): 
What are you interested in majoring in when you go to College?: 
You may select up to 5 options.
College Majors
Classification: 
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Highest Level of Education Completed: 
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Graduation Date (mm/dd/yyyy) - most recent: 
Major (Field of study): 
You may select up to 10 options.
Select all that apply
Undergraduate Institution of Study: 
You may select up to 5 options.
Colleges and Universities
Graduate Institution of Study: 
You may select up to 5 options.
Colleges and Universities
Career Information
Career Level: 
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Industry: 
You may select up to 5 options.
Available Options
Job Category: 
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Please select any professional credentials you have obtained.: 
You may select up to 999 options.
Credentials
Please list any other credentials here, or specify the details of any certifications described above
Do you own your own business?: 
Available Options
If you have a legal LLC, provide your dBA, EIN/TIN# for inclusion in NSBE database
NSBE Information
Where you exposed to STEM prior to College? If so, please describe briefly (program name, etc.). : 
Have you remained in engineering (or any STEM field) because of NSBE Programs?: 
Available Options
Yes No
Referred By: 
Enter Individual's Name, last name first and select the correct member from resulting list.
Are you interested in joining a technical Special Interest Group (SIG)?: 
You may select up to 7 options.
Choose any Special Interest Groups you are interested in getting more information on.
Energy Environmental
ITT Process Improvement
Public Policy Space
Women in Science and Engineering
Is this your first year as a Professional member of NSBE (NSBE AE)?: 
Available Options
Do you currently have a NSBE mentor? If so, please enter his/her name here to search NSBE's database: 
Enter Individual's Name, last name first and select the correct member from resulting list.
If you do not have a mentor, but are interested in being mentored. Please indicate here.
Do you have any of the following social networking accounts?: 
You may select up to 3 options.
Can we add you to our network on any of the following?
Facebook Twitter
LinkedIn
Other networks? Give us your twitter name and we'll follow you!
What is your interest level within NSBE AE?: 
How'd you like to get involved?
Mentor Tutor
Speaker Leadership
Chapter level only Donor
Conference Attendee
How did you hear about NSBE?: 
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Demographic
Gender: 
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Female Male
Race: 
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Country of Citizenship: 
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Please select the top 3 companies you'd like to work for. Answers used in NSBE 50 Survey.
1st Choice Employer (select one company): 
#, A-B
C-D
E-H
I-N
O-Z
Fill in your own option if you want to choose a company not on the lists above.
2nd Choice Employer (select one company): 
#, A-B
C-D
E-H
I-N
O-Z
Fill in your own option if you want to choose a company not on the lists above.
3rd Choice Employer (select one company): 
#, A-B
C-D
E-H
I-N
O-Z
Fill in your own option if you want to choose a company not on the lists above.
* = Required Field
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