Questionnaire Name * First Name Last Name Title Email Phone * (###) ### #### Type of Interview * Online In Person If online, do you have access to a webcam and decent internet? * Yes No N/A Preferred Date Available * This can be discussed further in the future to fit both of our schedules MM DD YYYY Current Place of Employment * Do you want your place of employment mentioned in the episode? Sure No Highest Level of Education Awards / Accomplishments * Additional Info * Anything additional that you would like mentioned in your introduction? Type N/A if no Recommendations of People to Interview Next (3) * Are there any questions or topics you'd like to discuss specifically? If yes, please list them here. Thanks for filling out the form! I look forward to speaking with you further and getting the interview set up. If you have any questions in the mean time, please do not hesitate to reach out!