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This convention will be a limited attendance event focused on activists throughout the community. As such, we ask you to fill out this application! Don't worry - its just a few questions to ascertain your interest! After you submit your application, IIC's Convention Team will contact you shortly!

Last Name:	MI	First Name
Address:	City	State	Zip Code
Birthdate

Contact Phone:		Email
Are you familiar with IIC?	Yes No	Are you 18 yrs of are or older?	Yes No
Is your email address registered on the IIC mailing list?			Yes No
Do you believe in Islam, as taught by the Holy Prophet Muhammad (SAW) and Ahlul Bayt (the 12 Imams)?			Yes No

Highest Level of Education	Name of School	Course of Study	Last Year Completed	Did you graduate?	List Diploma or Degree
School				Y N

List any pertinent organizational experiences and all current organizational affiliations
Do you have any experience with interfaith groups, media agencies, or in politics?
How do you think you can present Islam to the media, academic institutions, to non-Muslims and to other Muslims?
What are your thoughts on working with the government for the purpose of helping other Muslims?

References (Optional - Not Required)

Name		Title
Relation		Telephone

Name and Relationship		Title
Relationship		Telephone

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