* 1. Full name

* 2. Email address

* 3. Mobile phone number

* 4. LinkedIn Profile

* 5. What is your job title and employer/company? Or if a student please complete degree level e.g. MSC/PostDoc/PHD, area of study and institution.

* 6. Tell us about your curiosity in the 4th Industrial Revolution and why you want to learn more? 

* 7. What are the key opportunities and challenges for Northern Ireland innovation under the 4th Industrial Revolution?

* 8. Why do you want to be a 4IRC Connect Shaper?

* 9. Do you have the time to commit to the role of a Connect Shaper and participate in the programme fully? 

(12 month commitment. Compulsory quarterly ideations, and membership of one event sub team designing one of the monthly debates (work 3 months ahead) and optional monthly meetings to support other sub-teams in the design of their debate)

* 10. Reference contact details

* 11. How did you hear about Connect Shapers and 4th Industrial Revolution Challen