Web Survey

Facilitator preferred "Presentation(s)"

AA Service Work requires using first and last names; therefore. please state your first and last name when requested:

1. What is your age?

Under 20
20 to 29
30 to 39
40 to 49
50 to 59
60 to 69
70 to 79

2. What is your gender?

Male
Female

3. Personal Contact Info:

Name

Home Address

City

Zip Code

Home Phone

Cell Phone

4. If you are avaiilable to make presentations days, please indicate preferences:

8:00 a.m. - 11:59 a.m.
12:00 p.m. - 1:00 p.m.
1:00 p.m - 5:00 p.m.

5. Please indicate which days you prefer:

Sunday
Monday
Tuesday
Wesnesday
Thursday
Friday
Saturday

6. If you are available to make an evening(s) presentations, please indicate which

5:00 p.m. - 6:00 p.m.
6:00 p.m. - 7:00 p.m.
7:00 p.m. - 8:00: p.m.
8:00 p.m. - 9:00 p.m.

7. Please indiate which evening(s) you prefer to make presentations:

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

8. Please state in box below any issues you bellieve may be important to us:

Thank you for taking the tme to complete this survey