Personal Information

First Name:	M.I.: Last Name:
(Jr., Sr., etc.)	Date of Birth:
Employer / Organization Name (if applicable)
Street or POBox:	Business Address Home Address
City:	State: Please select... Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Country:
Home Phone:	Business Phone:
Fax:
Email:	(required to receive IWEA Digital Newsletter)

Were you referred to IWEA

Individual’s Name

Employer’s Name

What is the nature of your organization? (Please check the one that best describes the primary nature of your business)

	01	Municipal/district Water and Wastewater Systems and/or Plants
	02	Municipal/district Wastewater Only Systems and/or Plants
	03	Municipal/district Water Only Systems and/or Plants
	04	Industrial Systems/Plants (Manufacturing, Processing, Extraction)
	05	Consulting or Contracting Firm (e.g. Engineering, Contracting and Environmental)
	06	Government Agency (e.g., U.S. EPA, State Agency, etc.)
	07	Research or Analytical Laboratories
	08	Educational Institution (Colleges and Universities, Libraries, and other related organizations)
	09	Manufacturer of Water/Wastewater Equipment or Products
	10	Water/Wastewater Product Distributor Or Manufacturer’s Rep.
	11	Other (please specify)

What is your Primary JOB FUNCTION?

	01	Upper or Senior Management (e.g., President, Vice President, Owner, Director, Executive Director, General Manager, Mayor, etc.)
	02	Engineering, Laboratory and Operations Management (e.g., Superintendent, Manager, Section Head, Department Head Chief Engineer, Division Head, etc.)
	03	Engineering and Design Staff (e.g. Consulting Engineer, Civil Engineer, Mechanical Engineer, Chemical Engineer, Planning Engineer, etc.)
	04	Scientific and Research Staff (e.g., Chemist, Biologist, Analyst, Lab Technician, etc.)
	05	Operations (e.g., Shift Supervisor, Foreman, Plant Operator, Service Representative, Collection Systems Operator, etc.)
	06	Purchasing/Marketing/Sales (e.g., Purchasing, Sales Person, Market Representative, Market Analyst, etc.)
	07	Educator (e.g., Professor, Teacher, etc.)
	08	Student
	09	Other (please specify)

What areas do you consider to be your KEY FOCUS AREAS? (Please check all that apply)?

	01	Collection Systems		10	Stormwater
	02	Drinking Water		11	Toxic and Hazardous Material
	03	Industrial Water/Wastewater/ Process Water		12	Utility Management and Environmental
	04	Groundwater		13	Wastewater
	05	Odor/Air Emissions		14	Water Reuse and/or Recycle
	06	Land and Soil Systems		15	Watershed/Surface Water Systems
	07	Legislation (Policy, Legislation, Regulation)		16	Water/Wastewater Analysis and Health/Safety Water Systems
	08	Public Education/Information		17	Other (please specify)
	09	Residuals/Sludge/Biosolids/Solid Waste