Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please indicate if you work for an organization that serves: *

Underrepresented populations

Economically disadvantaged communities

None of the above

Do you work for an organization located in any of the following State of Maine counties? *

Aroostook

Franklin

Northern Penobscot

Piscataquis

Somerset

Washington

None of the above

Are you going to be traveling more than 100 miles one-way to attend the Conference? A $100 stipend will be granted to Scholarship Winners who are traveling more than 100 miles one-way to attend the Conference. *

Yes

No