Leadership CenLA Application

Application Instructions

Please complete all sections; try to limit answers to the spaces provided. If additional information is required, applicants will be contacted personally. Applications must be signed by the sponsor (if applicable) and candidate.

Applications should be submitted no later than March 18, 2024.

Personal Data

Last Name

Preferred Name

First Name

Preferred Title

(Mr/Mrs/Ms/Miss/Other)

Middle Name

Date of Birth

Email Address

Mailing Address or P.O Box

City

State

Zip Code

Years in CENLA

Work Phone

Cell Phone

Special Needs/Diets Accommodations

Please list any special accommodations you may need, i.e. any medical conditions, disabilities, or food allergies.

Organization/Business

Current Employer

Organization

Years with the Organization

Type of Organization

Business Phone

Organization Address

Present title or responsibility

Since

Education

Briefly summarize your educational history.

Answer the following:

Why would participation in this program be important to you and your organization?

Sponsoring Organization Recommendation

(Not applicable for independent applications)

This candidate has the organization’s full support to participate in this program. I am aware of the time commitment involved in his/her participation. Note: A supervisor or other official organization representative must complete this.

Sponsoring Organization Representative First and Last Name

Title

Date

Commitment

The tentative schedule of sessions for the 2023 program are listed below.

Time: 8:30 a.m. - 4:00 p.m.

Dress: Business Casual except for Capitol Day (TBD: Early - Mid May) and November session (Business Attire)

Dates: No session is scheduled for June or July (Subject to change if necessary):

March 28
April 25
May 23
August 29
September 19
October 31
November 21

I understand the purpose and commitments of this program. If I am accepted as a participant, I will devote the required time to the program.

Signature (Full Name)

Today's Date

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