CVAP Host Organization Application

Personal Information

Prefix

First Name*

Middle Name

Maiden Name

Last Name*

Suffix

Gender*

Primary Email*

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fellowship Start Year*

Fellowship Program Name*

Other

Fellowship Host Organization

Law School*

Graduation Year

Did you participate in an Equal Justice Works Law Student Program?*

Occupation | Job Title*

Industry

Company Name

Company Website

Professional Memberships

Business Email

Business Phone

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Willing to be contacted for mentoring?

Willing to be contacted regarding internships?

Willing to help with career programs and workshops?

Willing to present or train fellows and/or alumni on areas of expertise?

Willing to participate in fellowship and grant application reviews?

Willing to be contacted for program design consultations?

Willing to be contacted to speak at Equal Justice Works events?

Please identify your areas of expertise (subject and/or skills e.g litigation, coaching, facilitation)