CISPES Radical Roots
DELEGATION APPLICATION
Contact Information: Full Name *
As it appears in your passport.
Your answer
Name you prefer to go by?
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Birthday *
Must be 18 years of age or older to participate.
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DD
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YYYY
Gender *
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Passport Expiration Date *
MM
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DD
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YYYY
Email Address: *
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Cell Phone Number *
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Home Phone Number
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Street Address *
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City, State *
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Zip Code *
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Please list two references. Preferably someone involved in solidarity work, a social justice organization, a teacher or mentor. *
Include name, organizational affiliation (if any), your reference’s relationship to you, phone number, and email address.
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