Name Date

Full Address

City/State/Zip Code

Day time phone Evening phone

e-mail

How did you hear about interrupcion*?

Are you least 18 years old? YES NO -

Do you have car? YES NO -

How would you describe yourself as an individual?  Please write at least 5 words. 

Please choose one statement below that best describes how you might act in a situation where you are around a table with a bunch of people you don’t know:

“I am kind of outgoing and social, I wouldn’t be nervous to speak about myself but I wouldn’t be the person talking the most either.”

“I am a shy and private type of person, I don’t like to speak to people I don’t know, this would be an awkward situation for me.”

“I am outgoing naturally and very social, I would be interested in learning about the other people, I’d be talking a lot, I would probably make a few friends or acquaintances.”

Do you have experience in sales? YES NO -

Community involvement or outreach?  YES NO -

Organization and mobilization? YES NO -

If yes, please explain:

Do you know about the fair trade movement?  YES NO -   

What jobs or skills do you have that would make you a good interrupcion* agent*?

Please visit interrupcion.net and register as a “NEW PARTICIPANT.”  In the FudForum, click on ‘Interrupcion* USA’ – ‘Consumer Power’ to learn about the Responsible Consumption Campaign. 

Your interrupcion* Registered Username

How many hours a week would you like to work? 3 – 6 hours 6 – 15 hours 15+ hours -

Please indicate your availability (specify AM / PM).   Demonstrations are usually scheduled from noon to 3pm and from 4pm to 7pm, seven days a week. 

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