Contact NTAEL

1.	First Name: *

2.	Last Name: *

3.	Phone Number:* xxx-xxx-xxxx

4.	Email address:* email@website.com

5.	Have you been a part of our program?*
	--Please Select--Yes No

6.	What city and state do you live in?*

7.	What is the best time for us to contact you? Check all that apply. Select at least 1.
	Morning    Afternoon    Evening    Anytime

8.	What are you interested in?*
	English Classes (ESL)    High School Equivalency (GED)    Career Pathway Classes (CPW)    Feedback / More Information    Digital Literacy

9.	What kind of class are you wanting to take?*
	--Please Select--Face to Face Classes (in person)Remote Learning Classes (online)

10.	What time of day are you interested in classes?* Check all that apply. Select at least 1.
	Morning    Afternoon    Evening

11.	Do you have access to any of the following forms of technology?* Check all that apply. Select at least 1.
	Laptop    WIFI    Computer    Mobile Device with internet    Tablet    I do not have access to any of these    Other, please specify

12.	Do you know how to use the following?* Check all that apply. Select at least 1.
	Check and use Email    Sign in to website using an email and password    Use laptop or computer    Check for email attachments    Type in a full URL in the address bar    Navigate an internet browser    Know what a link or hyperlink is    Save a URL as a bookmark