Transportation Choices Summit and Advocacy Day 2012 Scholarship Application Form  
We appreciate your interest in participating in this important event.  TransForm is making scholarships available to community advocates and organizations representing low-income and people of color from across California.  We will be able to offer at least 30 full scholarships and are trying to secure additional funding to increase that amount.

Scholarships will cover long-distance travel, summit registration and, for participants staying both days, one night lodging in downtown Sacramento. It does not include local transportation. Preference may be given to people who can attend both days.  

If you are interested in a scholarship please fill out the information below.  Please contact Olga A. Bolotina at 510-910-4733 or Obolotina@transformca.org with any questions or concerns.


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Date of Application *
First Name *
Last Name *
Transportation Info *
Organization / Employer: *
Position: *
Did you hear about the summit through a specific organization? Please name. *
Organizational affiliation (if different than employer)
Street Address *
City *
(Street, City, Zip Code)
Zip Code *
Work Phone Number:     *
                                   
Email address:     *
                                   
Can attend: *
Do you have interest and/or expertise in effective public transportation, active and healthy transportation, or equitable transit-oriented development? If so, please briefly describe (75 words or less):
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