Leadership Sarpy Application - Sarpy Chamber , PAPILLION, NE

Leadership Sarpy Application
First Name

Last Name

Date of Birth *

Driver's License Number *

Country of Citizenship *

Company Name *

Job Title *

Email Address *

Work Phone Number *

Work Physical Address *

Cell Phone Number *

Home Address *

Direct Supervisor *

Direct Supervisor Email *

In your opinion, what are attributes of a leader? *

What do you see as challenges for today’s leaders? *

Do you live or work in Sarpy County? If so, how long? *

What do you see as challenges for Sarpy County in the near future? *

What interested you in Leadership Sarpy? *

What do you hope to gain from Leadership Sarpy? *

Please list 2 professional references and their contact information *

Are you aware of the cost for this program? *

Are you committed to making sure your schedule permits you to attend every class? (one full day a month for 9 months plus a two day retreat)

Will your company be paying for this course or will you be paying for this course personally?” *

Is your manager aware that you are applying for this course? *
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Refunds for credit card payments will be issued as a check paid to the company under which the registration was made. A 10% procession fee will be deducted from the refund amount.