First and Last Name:
E-mail address: 

Address (home):
City: State ZIP
Telephone Number:
Title: 
Current Employer:
School you attended:
Chapter City:
Chapter State:
High School Graduation Year:
College Graduation Year:
SkillsUSA (or VICA) Advisor Name:
Current Position: <pull down to select> Professional in the Field Instructor Student - High School Student - College/PS Business and Industry Partner Friend Other

Competition
Did you win a medal in a regional/district, state or national SkillsUSA competition?
Yes No
If yes, what contest?
What was your medal level? <pull down to select> Gold Silver Bronze
Was this at a regional/district, state or national level: <pull down to select> Regional/District State National
Are you still involved in SkillsUSA activities? Yes No
Would you be interested in serving on a technical committee?
Local Regional/District State National Not interested
Would you be interesting in helping judge?
Local Regional/District State National Not interested

Employability Skills
Have you taken any levels of the Professional Development Program?
Yes No
If yes, what level did you complete? (1-5)

Have you studied the Career Skills Education Program (CSEP)?
Yes No