Pre-Purchase Registration & Scholarship Form | NACA's Economic Justice & Advocacy Center

Personal Information

Name(Required)

First Last

Mailing Address

Phone(Required)

Email(Required)

Organization Information

Organization Type(Required)

Organization Name(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Website(Required)

Scholarship Application

If you work for a HUD Approved Non-Profit Counseling Organization, or if you are a member of an affiliate HBCU, select a scholarship type from the options below. Otherwise, select Self-Pay.

Pre-Purchase Counseling Training Dates(Required)

Training Dates

Scholarship Type(Required)

Live Webinar Training

Scholarship Eligibility Type(Required)

HCA

HBCU Student

HBCU Alumni

HBCU Faculty or Staff

None of the above

HBCU(Required)

HBCU Identifier (Title, Student ID, Graduation Date)(Required)

HUD Agency ID Number(Required)

Demographic Information

Are you a person with a disability?(Required)

YES

NO

Do you live or work in a rural area?(Required)

YES

NO

Do you live or work in a low-income area?(Required)

YES

NO

Are you LEP (Limited English Proficient)?(Required)

YES

NO

If you selected yes, what language do you speak?

Disclaimer And Signature

Once scholarship for travel and lodging reservation(s) have been confirmed and approved, any flights and/or lodging reservations that are cancelled or no show will be subject to a cancellation fee at the full cost of the travel and accommodations booked.

Disclaimer(Required)

By checking this box and providing my E-signature, I certify that the information provided is true and complete to the best of my knowledge.

E-Signature: Please type your full name below(Required)

Date(Required)