First name
Last name
Home address
State
Zip
Home phone
Cell phone
E-mail address
Occupation
Business address
Work phone
This program is for pro-choice women candidates running for office in 2010. Which office and district are you seeking election to in 2010? (50 word text box)
Please tell us in 750 words or less why you consider yourself a compelling and viable candidate. (750 word text box)
Send current resume to Debra Fitzpatrick at harex004@umn.edu.
This program requires one reference. Please provide information on your reference:
Reference name
Reference phone
Reference e-mail
Details about program content and scheduling (jpg format, Microsoft Powerpoint format).
In submitting this application I affirm that:
I am a pro-choice woman and declared candidate seeking office in 2010. If selected I will complete the program in its entirety. I may be dismissed from the program due to lack of interest, unsatisfactory attendance, progress or conduct, violation of confidences shared during the program, or other reasons deemed to be detrimental to the overall program.
** I understand that if accepted into the program, my attendance is mandatory at all sessions, except in case of emergency.***
I agree to the program terms.
The registration fee for this program is $200 to partially cover food and materials. All collaborating organizations are significantly subsidizing your participation. We need your contribution as well. Limited, partial scholarships (up to $125) are available.
I can pay the $200 registration fee. I will need a scholarship to participate. I can pay $ . Registration fees are due by March 30, 2009. Mail checks to:
The Center on Women and Public Policy Attn: Debra Fitzpatrick 264 Humphrey Center 301 19th Avenue South Minneapolis, MN 55455.
If the form is not working properly or if you have other questions, you can send an e-mail message to Debra Fitzpatrick at harex004@umn.edu. Please include all the information listed above in your message.
