* 1. Name:

* 2. Address:

* 3. Phone number:

* 4. Email address:

* 5. School/ Organization (if applicable):

* 6. What is your interest in attending “Bridging the Gap: Connecting Black Communities to the Green Economy”?

* 7. If granted a scholarship, do you commit to attending the entire session and taking action after the event?

* 8. I certify that all information above is accurate and correct (Type name):

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