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* 1. Please indicate how you qualify for the CLSI. (Select more than one if applicable).

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* 2. Please list the cooperatives and/or cooperative organizations with which you have been affiliated and your role(s).

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* 3. Describe your interest in cooperatives and what you hope to get from the Cooperative Leaders and Scholars Institute. Please do so in 300 words or fewer.

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* 4. Please give us the name of your recommender.

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* 5. Please give us the title of your recommender.

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* 6. Please give us the email address of your recommender.

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* 7. Please upload your recommendation. Word or PDF format please.

PDF, DOCX, DOC file types only.
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* 8. Do you have any dietary restrictions we should be aware of?

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* 9. Do you consent for NCBA CLUSA and CDF to use images of you, video recordings, etc. taken while you attend the CLSI? These will be used in CLSI and IMPACT Conference related materials, published on our websites, publications, etc.

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* 10. Please provide your name, contact information and - if you'd like - preferred pronouns.

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