Defining Leadership Application Form

Important Information

Please note: Attendance is required at all sessions, as each session builds upon the previous. Please ensure you are able to attend all program sessions before you apply.

Series Applying For:

First Name

Preferred Name:

Last Name:

Title (i.e. Director of Marketing):

Company Name:

Business Address:

Business Address 2:

Business City:

Business State

Business ZIP/Postal Code

Business Phone:

Business Email:

Personal Email:

Business Fax:

Home Address:

Home City

Home State

Home ZIP/Postal Code:

Phone:

Cell Phone:

Defining Leadership begins with a Program Orientation Event and Closing Celebration for your supervisor and/or company sponsor to attend with you:

Who is authorizing/sponsoring your participation in the program?

First Name

Last Name

Title:

Email:

Who is your direct supervisor?

First Name

Last Name:

Title:

Email:

Are there any dietary restrictions or special accommodations you require?

Please provide your education history

College 1 Information:

Name:

Location (City, State):

Dates:

Degree (i.e. BA, BS, MBA)

Major:

Honors:

College 2 Information:

Name:

Location (City, State):

Dates:

Degree (i.e. BA, BS, MBA)

Major:

Honors:

Please provide a brief history of employment in chronological order, starting with your present position.

Organization 1 Information:

Name:

Dates:

Title:

Organization 2 Information:

Name:

Dates:

Title:

Organization 3 Information:

Name:

Dates:

Title:

Number of years in Supervisory Role:

Annual Compensation:

Please list any leadership or management development programs attended:

Please give a brief description of your career objectives:

Briefly explain why you want to participate in Defining Leadership:

The richness of the program is increased and learning enhanced when differences in individuals are present. What differences in perspective might you bring?

Have you ever attended an ICAN program?:

Please list ICAN programs you've attended:

Have you applied to ICAN's Defining Leadership program before?:

Please list community, civic, business, professional and social organizations in which you are an active member:

Please select those items in which you have an interest:

Being a mentorHaving a mentorHaving a professional coach

Complete the following questions ONLY if you work for a nonprofit organization with 50 employees or less.

Organization Name

Executive Director:

# of Employees:

Headquarters Location:

Who recommended you for this program?

What are your job accountabilities?:

How long have you been in this position?:

How did you hear about the ICAN Scholarship?:

Web Site:

NAM Member:

Operating Budget:

OFFER CODE

If you DO NOT wish for your pictures or comments to be used in ICAN promotional materials please check the box.

I UNDERSTAND THAT ALL INFORMATION SUBMITTED WILL BE USED BY THE ICAN, INC. OFFICE AND THE SELECTION COMMITTEE ONLY. FACILITATORS PLEDGE ABSOLUTE CONFIDENTIALITY REGARDING INFORMATION CONTAINED IN ALL ASSESSMENTS. I UNDERSTAND THAT SUBMISSION OF THIS COMPLETED APPLICATION INDICATES THAT BOTH MY EMPLOYER AND I HAVE REVIEWED AND ACCEPT THE PROGRAM'S REQUIRED COMMITMENT OF TIME AND FINANCIAL RESOURCES. TUITION IS NONREFUNDABLE. SUBMISSION OF A COMPLETED APPLICATION INDICATES YOU ACCEPT THESE REFUND TERMS.

I accept these terms

Please note: Once your application is received, you will receive an email confirmation from ICAN. IF YOU DO NOT RECEIVE AN EMAIL WITHIN THE NEXT BUSINESS WEEK, please contact ICAN at ican@icanglobal.net to confirm receipt of your application.

Contact Information