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:

Home Address

Home City

Home State

Home ZIP/Postal Code:

Phone:

Cell Phone:

Where would you like program materials mailed to?

Home AddressBusiness Address

Do you currently manage / supervise people?

YesNo

Number of years in Supervisory Role:

Have you ever attended an ICAN program?:

Please list ICAN programs you've attended:

If you DO NOT wish for your picture 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 (STANDARD RATE OF $1,000) 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@icanleaders.org to confirm receipt of your application.

Contact Information