| | | | | |       Listen to Me       | | | | | |

Last Name: [your last name]
First Name & Initials: [first name and initials]
Joined Kurzweil AI: [month, year]
Left Kurzweil AI: [month, year]

Please enter an "x" in the [ ] for the department(s) you worked in:
Customer Support (Waltham) . . . . . .[ ]
Education/Technical Writing . . . . . [ ]
Finance & Administration . . . . . . .[ ]
Manufacturing . . . . . . . . . . . . [ ]
Marketing/Product Management . . . . .[ ]
Research & Development . . . . . . . .[ ]
Sales (Field) . . . . . . . . . . . . [ ]
Sales (Waltham) . . . . . . . . . . . [ ]
Voice Applications Specialist (Field) [ ]

Current Employer: [Name of employer]
Employer Address: [Full mailing address of employer]
Employer Homepage URL: [World Wide Web address for employer]
Business Phone Number: [Your business phone number]
Business FAX Number: [Your business FAX number]
Business E-mail: [Your business e-mail address]

Home Address: [Full home mailing address]
Home Phone Number: [Your home phone number]
Home FAX Number: [Your home FAX number]
Home E-mail: [Your home e-mail address]
Personal Homepage URL: [Your personal Web page address]

For each of the next 3 items, please indicate "home" or "business"
Preferred mailing address: []
Preferred phone number: []
Preferred E-mail address: []

Account Information:
Username: []
Password: []
Confirmation E-mail Address (if different than replying to this message):
	[]