Pre-Purchase Registration & Scholarship Form Pre-Purchase Trainings Pre-Purchase Training Step 1 of 5 20% Personal InformationName(Required) First Last Mailing Address (Required)(Required) Phone(Required)Email(Required) Organization InformationOrganization Type(Required)SelectHUD Approved OrganizationAffiliate HBCUOther OrganizationOrganization Name(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Website(Required) Scholarship ApplicationIf 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)Self-PaceTraining Dates Scholarship Type(Required) Online Training Scholarship Eligibility Type(Required) HCA HBCU Student HBCU Alumni HBCU Faculty or Staff None of the above HBCU(Required)SelectAllen UniversityBenedict UniversityEdward UniversityJohnson C. Smith UniversityLivingston CollegeMiles CollegePhilander Smith CollegeShaw UniversityStillman CollegeVirgina Union UniversityWilberforce UniversityWiley CollegeHBCU Identifier (Title, Student ID, Graduation Date)(Required) HUD Agency ID Number(Required) Demographic InformationAre 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 SignatureOnce 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) MM slash DD slash YYYY Δ