Name *

Email *

Phone Number *

Date of Birth *

Business Category *

Enter required value Banking Financial Services Construction Education Government Healthcare Nonprofit Real Estate Agriculture

What is your job title? *

Civic, Professional or Volunteer activities (please list current organizations you are active) *

How would you use your leadership training and experiences to benefit the community? *

Tell us something you are passionate about seeing changed or made better in our community. *

We may take topics and ideas from each submission to create the class project.

Participation Agreement *

I have read, understood, and accepted the expectations of the program. I understand if I do not meet the expectations, I will be dismissed from the program without a refund.

Employer Agreement *

I have read, understood, and accepted the expectations of the program. I understand my employee will be held to these expectations and if they are not met, they will be dismissed from the program without a refund.

Employer/Supervisor's Name *

Employer/Supervisor's Email *

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