Application for World Wide Views on Climate and Energy Phoenix, AZ

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1 Application for World Wide Views on Climate and Energy Phoenix, AZ Thank you for applying to be part of the Arizona deliberations for World Wide Views on Climate and Energy. To learn more about the global program, go to: The program will take place in Tempe, AZ at the Arizona State University campus on June, 201. Applicants must be at least 18 years of age. Muchas gracias por su interés en formar parte de las deliberaciones para Visiones Globales sobre Clima y Energía en Arizona. Para obtener más información sobre el programa global visite nuestra pagina de Internet: El programa tendrá lugar en Arizona State University el de junio de 201. Los solicitantes deben tener al menos 18 años de edad. 1. The event will be presented in English, but we welcome participants whose preferred language is Spanish and we can provide interpreters on request. Would you be comfortable participating in the event at a bilingual table? El evento se presentará en inglés, pero damos la bienvenida los participantes que prefirieren el español y tendremis intérpretes disponibles si lo piden. Sería cómodo participando en el evento de una mesa bilingüe? Otros Yes / Sí No / No 2. Would you prefer to complete the application in English or Spanish? Prefiere completar la solicitud en inglés o en español? English / Inglés Spanish / Español Page 1

2 WWViews on Climate and Energy AZ Applicant Information Thank you for applying to be part of the Arizona deliberations for World Wide Views on Climate and Energy. To learn more about the global program, go to: We will choose 100 participants from several hundred applicants based on a number of factors in order to ensure a diversity of experiences and views among our participant group. These factors include: (a) Age, (b) Gender, (c) Race/Ethnicity, (d) Income, (e) Educational Level, (f) Occupation, and (g) Geographical Zone. Criteria and categories are adapted from the 2010 U.S. Census. Since we will be selecting participants on the basis of these criteria, answering questions about them is a necessary requirement for applying to be part of the World Wide Views on Climate and Energy program. The program will take place at Arizona State University on June, 201. Applicants must be at least 18 years of age. We will let you know whether or not you have been accepted to participate by mid May. If you are not selected, there may still be opportunities to participate in public events based on WWViews at the Arizona State University. We will let you know. Please answer as fully and accurately as possible so that we can assure that a range of viewpoints are represented at the deliberation. Thank you for your interest in WWViews on Climate and Energy! Questions? Need assistance? Please Levi Espinoza. 1. What is your first name? Please note that we need your real full name and phone number in order to provide the stipend payment for participation. 2. What is your last name? 3. What is your address? We will only use your address to correspond with you about World Wide Views on Climate and Energy. We will never give your address to another party. Address: 4. What is your phone number? Phone Number: Street. What is the street name and number for your mailing address? Page 2

3 . What city do you live in? City/Town: ZIP: 7. What is your zip code? (enter digit ZIP code; for example, 0044 or 9430) 8. What state do you live in? State: 9. Which of the following would you say describes the area where you live? Urban Suburban Rural 10. Are you male or female? Male Female 11. What is your age? What is your household income per year? Less than $2,000 $2,000 to 49,999 $0,000 to 99,999 $100,000 or more Page 3

4 13. What race/ethnicity best describes you? White, not Hispanic Black, not Hispanic Asian Hispanic or Latino Mixed race Other (please specify) 14. What is the highest level of education you have completed? No high school diploma or GED earned High school degree or equivalency Some college Bachelor s degree Graduate or professional degree 1. Which of the following best describes your occupational situation? Employed Unemployed Retired Student Other 1. If you are employed, what is your: Occupation? Industry? 17. Are you professionally involved in climate or energy issues through your work or business? Yes No Page 4

5 18. If you are professionally involved with the issue of climate or energy, please describe how you are involved: 19. Are you member of an environmental organization? (a non governmental organization that works actively and politically to promote sustainable development and to promote environmental protection) Yes, an active member Yes, a passive member No 20. Do you have any accessibility needs or accommodation requests that we should be aware of? 21. How did you hear about this program? Page