* 1. Name

* 2. Affiliation/School/Organization (if any)

* 3. Email Address

* 4. Phone Number (please include mobile number if possible)

* 5. Mailing Address

* 6. Please check all boxes that apply to you:

* 7. Which day(s) are you committed to attend, if provided scholarship? (Please note if unused scholarship means someone else didn't get a chance to attend.)

* 8. Why are you interested in attending the Living the Next Economy Convergence? (What do you hope to get out of and contributing to the gathering?) And What kind of work/projects are you involved with in your community?

* 9. Would you be interested in volunteering at LNE? (If so, please fill out the LNE Volunteer form.)

* 10. Are you able/willing to make any financial contribution to help us cover the costs? (Any amount of $10, $20, $30 would help, thank you!) Click here to make a donation!

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