Team Leader /Contact Person

Team Leader must be a student or recent graduate member.  The contact information listed below will be used as the primary method of contact for all Economic Fuel notices. Participants must notify Economic Fuel of any changes made to this information. Economic Fuel will not be responsible for any missed notices. 

1. Team Leader Name: _________________________________ Date of Birth:_______________

Email Address: ________________________________________ Phone:_________________

Mailing Address: ______________________________________________________________

City: ____________________________ State: ________________ Zip Code:_____________

Humboldt County Residency Since:____________________

School/Institution:____________________________________________________________

Major:______________________________________________________________________

Eligibility Status (circle one):          Student          Recent Graduate

For Current Students:  Unit Load:   Fall 2008 _____ Winter 2009 _____ Spring 2009 _____
     
For Recent Graduates:   Graduation Date______________________
     

Signature:                                                       ________    Date: _________________