New Orleans IIA Member Survey - 2012
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1. Member Information

1. Please provide the following information. Leave this section blank if you would prefer to complete the form anonymously.

Please provide the following information. Leave this section blank if you would prefer to complete the form anonymously. First Name:
Last Name:
Organization:
Title:
Phone Number:
Email:

2. Please indicate your membership and certification status.

	Yes	No
Are you a member?	*Please indicate your membership and certification status. Are you a member? Yes	Are you a member? No
Are you a CIA?	Are you a CIA? Yes	Are you a CIA? No
(If not, would you be interested in a CIA prep class?)	(If not, would you be interested in a CIA prep class?) Yes	(If not, would you be interested in a CIA prep class?) No

3. FOR MEMBERS ONLY:

	Yes	No
1. Is it okay for the New Orleans Chapter of the IIA to include my name, title, certifications, organization, phone number and email address in a chapter directory that will be posted in the member's only section of the Chapter's website?	*FOR MEMBERS ONLY: 1. Is it okay for the New Orleans Chapter of the IIA to include my name, title, certifications, organization, phone number and email address in a chapter directory that will be posted in the member's only section of the Chapter's website? Yes	1. Is it okay for the New Orleans Chapter of the IIA to include my name, title, certifications, organization, phone number and email address in a chapter directory that will be posted in the member's only section of the Chapter's website? No
2. Would you be interested in helping with Chapter activities?	2. Would you be interested in helping with Chapter activities? Yes	2. Would you be interested in helping with Chapter activities? No

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