Last NameFirst NameMiddle Initial

Street Address

CityState
ZIP Code

Phone NumberAlternate Phone Number

Email address

Employer / School

Job Title / Major

Birth Date
Marital Status

Gender Identity
Sexual Orientation

Educational Level
Salary Range

Number of Children Rent or Own Your Home

How did you hear about LinkOUT? (Check all that apply)

• Web Search
• Stonewall Columbus
• Media Outlet - Please Identify:
• Word of Mouth

Why did you join LinkOUT? (Check all that apply)

• Networking Opportunities
• Volunteer Opportunities
• Professional Development Events
• Social Events
• Education
• Other - Please Identify:

What LinkOUT committees would you like to learn more about? (Check all that apply)

• Fundraising
• Education/Professional Development
• Community Service
• Membership
• Social
• Marketing

What three things are you looking for from LinkOUT?

Are you a business owner or manager with an interest in building a relationship with Columbus’ professional LGBT community? Please tell us about yourself, your business and your interests.