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 2010 _____ Winter 2011 _____ Spring 2011_____
     
For Recent Graduates:   Graduation Date______________________

Have you been convicted of, or plead no contest to, a misdemeanor or a felony? Yes No

Are you currently involved with any pending legal action? Yes No

If your answer is yes to either, please explain:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

Signature:                                                       ________    Date: _________________