Thank you for the commitment to being part of Larry's Witnesses and wanting to 'Burn The Word'. Please complete the Mission Request Form below; once completed a Larry's Witnesses representative will contact you to finalize your mission submission within 3-5 Business Days. After you complete the Mission Request, you will be directed to a Confirmation page. This page will contain important Mission information, including your Mission Number. You should print this page for your records. If you have any questions or wish to check the status of your Mission Request, you will need this Mission Number. We will keep you informed via e-mail as your Mission Request is processed.

Note: For faster service call the Larry's Witnesses Hotline - 602.332.9825
Name: *
Email Address: *
Phone:
Address: *
City: *
State: *	Please Select International Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip Code: *
What Years Have You Attended Burning Man?
	1986 1990 1994 1998 2002 2006 1987 1991 1995 1999 2003 2007 1988 1992 1996 2000 2004 2008 1989 1993 1997 2001 2005 2009 2010 2011 VIRGIN!
What days are you available to 'Spread The Word'? (6-Hour Shifts)
	Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday
Current Medical Conditions/Issues:
	Nervous Tick	Bladder Disorder	Emotional Wreck
	Fart Excessively	Bushy Eyebrows	Talk with Hands
	Contacts/Glasses	Knuckle Cracker	Excessive Blinking
	Currently seeing a Therapist?
	Regularly use FUCK in your vocabulary
Measuring Your Determination:
On a scale of 1 to 10, with 10 meaning "Very Freakin Seriously", how seriously are you committed to spreading - 'Burn The Word'?
	Select One 10 9 8 7 6 5 4 3 2 1
Special skills: Language proficiency (other than English) Computer skills?
Please use the following to characterize yourself? (Choose all that apply)
	Leader	Proactive	Compassionate
	Logical	Independent	Understanding
	Quirky	Eclectic	Confident
Please list Five (5) people that will vouch for you:
Will you be available for phone and/or online debrief sessions Post Playa 2012?
	Yes  No
# people you think you will convert to 'The Word of Larry' during your mission?
	1	2 - 5	5 - 10
	20 - 50	100 - 500	800 - 1600
	2000 - 5000	5000 - 10000	10000+
Please use the following to characterize Larry Harvey? (Choose all that apply)
	Rebellious	Unique	Generous
	Friendly	Results-Driven	Naive
	Open Minded	Controversial	Wise