NOTE: ALL FIELDS REQUIRED

APPLICANT INFORMATION

Your Name

Your Email

Home Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

EMPLOYEE SPONSORSHIP INFORMATION

Contact Name

Position

Company

Address

City

State

Zip

E-mail

Phone

TUITION PAYMENT AGREEMENT

Tuition for 2012 is $2250, which includes additional fees for overnight retreats. I hereby agree to personally pay $100 of the tuition cost, the balance to be paid by sponsor. Tuition is non-refundable, and must be paid in full prior to the opening retreat.

Amount Paid by Applicant

Applicant Signature
 I agree to the above terms

Date

Amount Paid by Sponsor

Sponsor Signature
 I agree to the above terms

Date

APPLICATION REQUIREMENTS

A completed application includes this completed form, a current resume and essay answers to the following questions:

Please list what you believe to be the most significant issues of living or working in Niagara County.

How do you think you could contribute to the solution of these issues?

What is your definition of leader?

Please list your most notable accomplishments.

Please Attach Your Resume Here:
(Only MS Word or PDF's Accepted)

Eligible candidates will be interviewed prior to acceptance. Full attendance at all monthly sessions and overnight retreats is required. A complete schedule is available online or by calling Leadership Niagara at 716-949-3223. Please note that tuition covers all programs, materials and accommodations at overnight retreats.

Our Vision: To be the premier leadership resource for our region that creates trustees of our community who work together to shape our future.

Leadership Niagara • 1623 Military Road #332 Niagara Falls, NY 14304 • 716-949-3223