Contact Information

First Name :

Last Name:

Title :

Company :

Address 1 :

Address 2:

City :

State :

Zip Code :

Phone :

Fax :

Email Address :

Company Information

Are you a vendor?

Yes No  (Any organization whose primary source of revenue is related to products and/or services related to the IT industry).

Who do you report to?

Annual Revenues :

  (Please Clarify as appropriate based on your organizations revenue structure)

No. of Employees

Company Wide :

Divisonal Wide :

Within IT Org. :

Company Function

Company Structure

Product Lines

General Technical Information

Information Technology (Projects/Issues)

General Information

How did you find out about the CIO Group?

Do you know any of the existing members?

What do you hope to get out of your membership in this organization?