SMI Registration Form

If you wish to be kept informed of Social Marketing Institute news and events please complete the following form.

Let us know about your areas of expertise in the field of marketing as we often receive requests for consultants with particular skills. Also please indicate any areas in which you need help and assistance you are willing to provide to the Institute.

PERSONAL INFORMATION
** Indicates Required Field
**Title: Mr. Ms. Dr. Prof.
**First Name:
Middle Initial:
**Last Name:
Highest Degree Held:
Job Title:
Work Phone:
Extension:
Work Fax:
E-mail:
Areas of Expertise:
(Hold down Ctrl key to make
multiple selections)
Comments:
1. Help you need.
2. Assistance you are willing to give.

ORGANIZATION/INSTITUTION
**Name of Organization:
**Category:
**Address Line 1:
Address Line 2:
Address Line 3:
**City:
**State/Province:
**Postal Code:
**Country:
Organization Website:

**Before submitting this form, please indicate your privacy preferences by responding to the following questions:
1) Do you authorize us to release your name and address to approved social marketing groups?

Yes, you may release my name and address
No, do not release my name and address

2) Do you want us to include you in a skill bank of social marketing professionals (for possible release to those seeking assistance)?

Yes, include me in your skill bank
No, do not include me in your skill bank