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PLEASE TYPE OR PRINT
DESCRIPTION OF YOUR PRESENT
RESPONSIBILITIES
BRIEF DESCRIPTION OF YOUR ORGANIZATION
number of employees, annual operating budget, function
or service provided, etc.
PREVIOUS EMPLOYMENT HISTORY
in reverse chronological order
Mr. Ms.
Last Name First Name MI
Preferred Name Date of Birth
Title Organization
Office Address
City State Zip
Office Phone Cell Phone Fax
Email Years in Current Position
Name of Organization Title/Position Dates: From–To
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You may download a printable version of this form from our website: http://sei.coopercenter.org/
Select program preference
Jan 20-26, 2018
Feb 24-March 2, 2018
March 24-30, 2018
August 18-24, 2018
September 8-14, 2018
November 10-16, 2018
EDUCATIONinclude intensive management
development programs
WHY DO YOU WANT TO PARTICIPATE IN
LEAD?
MYERS BRIGGS
ACCOMMODATIONS
POLO SHIRT SIZE
SIGNATURE OF APPLICANT
FEES
DISCOUNTS
REFUNDS & CANCELLATIONS
DEADLINES
EMAIL TO
Institution Degree/Program Dates: From–To
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Are you familiar with the Myers Briggs Type Indicator? No Yes Type _____________
All rooms are non-smoking
Small Medium Large X-Large XX-Large
Signature of Applicant _________________ Date
A special e�ort is made to keep LEAD reasonably priced. The fee of $4,450 includes the cost of in-struction, all materials, most meals, and housing. Unless prior arrangements have been made, fees are due one month before the start of LEAD.
A 10% discount is granted to any participant from a Virginia locality that is a member of the Virginia Institute of Government. (LEAD-$4,005)Virginia Institute of Government Member; Yes No
A 50% fee will be assessed for cancellations within two weeks of the beginning of the program. Substitutions acceptable to LEAD may be made up to two weeks before the start of the program.
Please tell us how you heard about LEAD.
Name Title
wwwwwwwwwww
Locality
wwwwwwwwwww
Other
Application required 8 weeks before the start of the program
Payment is due 1 month before the start of program.
Carmie Rodriguez, LEAD Program [email protected]. Box 400206 • Charlottesville, VA 22904-4206434/243-5031 • Fax: 434/982-5524 • TDD: 434/982-HEAR
