Fields with asterisks (*) are required.

First name *

Last name *

Email *

Labor Organization/Union

Local Union Number

Address *

City *

State *

Zip code *

Phone number *

Name of your employer, the length of your employment and a brief job description. *

What community or labor based organizations are you affiliated with? Do you hold office with these organizations? *

Why are you a good candidate to receive a scholarship? How will attending the WISE conference help advance either your personal, professional or organization’s goals? *