Full name

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* 1. Full name

Email address

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* 2. Email address

Mobile phone number

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* 3. Mobile phone number

LinkedIn Profile

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* 4. LinkedIn Profile

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.

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* 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.

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

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

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

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

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

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

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)

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* 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)

Reference contact details

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* 10. Reference contact details

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

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

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