APPLICATION FORM V3. 2016

NAME: Click here to enter text. DATE OF BIRTH: Click here to enter a date. GENDER: Choose an item. AGE: Choose an item. CONTACT: Mobile: Click here to enter text. Home: Click here to enter text. Work: Click here to enter text. Email Address: Click here to enter text.

EMERGENCY CONTACT: Name: Click here to enter text. Phone: Click here to enter text. Email: Click here to enter text.

HIGHEST EDUCATION: Choose an item.

Other, please specify: Click here to enter text. Currently pursuing: Choose an item. AREA OF STUDY: Click here to enter text.

OCCUPATION: Click here to enter text. Industry: Click here to enter text.

CONSTITUENCY: Choose an item.

ARE YOU A MEMBER OF THE PNM?Choose an item. IF YES WHAT PARTY GROUP: Click here to enter text. IF NO ARE YOU INTERESTED IN JOINING?: Choose an item. PROFESSIONAL EXPERTISE: Politics ☐ Protective Services ☐ Tourism/Hospitality ☐ Human Resources ☐ Agriculture ☐ Medical/ Healthcare ☐ Energy/ Oil & Gas ☐ Legal ☐ Engineering ☐ Project Management ☐ Purchasing/Sales ☐ IT/IS/CSA/Internet ☐ Environmental/ Health & Safety ☐ Finance/Accounting/ Banking ☐ Education ☐ Childcare ☐ Science/Pharmaceuticals ☐ Marketing/Media/Communications ☐ Manufacturing/Production ☐ Administration ☐ Tourism/Hospitality ☐ Social Work/Psychology ☐ Other: Click here to enter text. PLEASE CHOOSE WHICH HELICONIA COMMITTEES MOST INTEREST YOU (MAY CHOOSE MORE THAN ONE): Membership Committee ☐ Policy/Legislation/Research ☐ Marketing and Branding ☐ Fund Raising/ Financing ☐ Projects Events & Operations ☐ Public Relations ☐ Legal ☐ Marketing & Communications ☐

PLEASE SELECT YOUR INTERESTS: Fundraising ☐ Social Work ☐ Volunteerism ☐ Outdoor Activities(hiking etc) ☐ Professional Networking ☐ Family Day Activities ☐ Cooking ☐ Skill sharing & Development workshops ☐ Other: Click here to enter text.

HOW DID YOU HEAR ABOUT HELICONIA? Social Media ☐ Through friend/family ☐ Traditional Media(newspaper/TV) ☐ Party member ☐ Heliconia Member ☐ IF YES ENTER NAME: Click here to enter text. Why would you like to join Heliconia Foundation? Click here to enter text. How do you think the Heliconia Foundation can benefit you? Click here to enter text. How best can you add value to Heliconia Foundation? Click here to enter text. Please provide any suggestions: Click here to enter text. Thank you……………………………