2021 2022 Executive Leadership Application
Please clearly print or type all answers and complete four page application fully.
I. General Information
Full Name Preferred First Name
Title Organization
Work Address Zip
Work Phone Work Email
Home Address Zip
Cell Phone Home Email
Assistant Name ____________________ Assistant Phone ________________________
Preferred Mailing Address Home Work Preferred Email Home Work
Please check how you learned about the Momentum program:
_____ My organization recommended me____
Momentum Alumna Name:
Friend/Family Member
Other (please specify)
Ethnicity: (optional)
African American Caucasian Hispanic/Latina Native American
American/Pacific Islander ___ Other ____________________________
Educational: (Check all that apply)
PhD EdD JD MBA MA/MS BA/BS ___ Other
Undergraduate degree from _______________________________ graduation date _________
Graduate degree from ____________________________________ graduation date _________
Please check the sector in which you are employed:
Corporate/Business Government Education Entrepreneur Non-profit
___ Other
Annual Budget of Organization:
<$500,000 $500,000 to $5 million $5 million to $100 million ___>$100 million
Number of Employees:
<50 50 to 499 500 to 5,000 >5,000
Email completed application for receipt by April 30, 2021
to: application@momentumleaders.org
I report to:
Head of Division
Board of Directors/Trustees
I own the company Other
II. Please complete the following questions
limiting your replies to space available
1. Briefly describe your present job function and responsibilities (include length of time in the
organization and in this position).
2. What is the largest budget you have overseen? _______
3. What is the largest number of FTE’s you have directly supervised?____ Indirectly? _____
4. How many FTE’s currently report directly to you? ______ Indirectly? ______
5. Briefly self-describe your leadership style:
6. Would you agree to your supervisor completing a questionnaire about you? yes no
If so, to whom do you report ?
7. What other leadership programs have you attended?
8. What are your greatest areas of satisfaction in the work you do?
9. What are your greatest challenges/difficulties in reaching your career goals?
10. Describe your most important civic/volunteer activities during the past five years, noting any
special awards, citations, or leadership experience.
11. Specifically, what do you hope to gain by participating in Momentum?
12. Mentoring
a. Momentum may pair you with an experienced local mentor. What would you most like to
achieve as a result of having a mentor assist you with personal/professional growth?
b. Have you had the opportunity to mentor others? If so how?
c. An alumnae requirement for Momentum graduates is to become a mentor to a woman or
girl. What thoughts do you have about what you might expect to gi
ve/receive through
such a commitment?
13. What leadership assessment instruments have you completed in the last five years?
ESCI Myers-Briggs
______ Dimensions of Leadership Profile DISC
Emotional Conflict Inventory (ECI)
California Psychological Inventory ___
A 360 feedback instrument What?
? What?
III. Please check appropriate space
If selected as a participant:
My organization will cover my $4,500 tuition in full.
I will assume responsibility for my tuition in full.
I would need a scholarship in order to attend this program. (Momentum will contact
you for specifics.)
IV. Please initial before each statement
I certify that all statements made in this application are true, complete and correct to the best of
my knowledge and are made i
n good faith. I know and understand that all information may be
verified. If selected, I have my company or organization’s support for my participation, if
applicable, and I will attend retreat and all sessions in their entirety. See Session Dates below.
If selected, I will remit the tuition fee on or before July 16 ,2021 to Momentum to reserve my
place. I understand that if my tuition is not paid by that date, my place can be forfeited to
another applicant on the waiting list. I also understand that my tuition payment is non-refundable
and non-transferable.
Additional documents required to complete your application:
1) Brief resume which includes (at a minimum) employment history for last 10 years, as well as
volunteer activities for the same period
2)Organizational chart that reflects both your reporting structure and those positions reporting
to you
3)One letter of recommendation that speaks to your demonstrated leadership in high-level
projects or initiatives
Each year Momentum receives many more applications than we can accept. Our selection
committee strives for a broad range of organizations from different industries, as well as
individuals with varied roles, backgrounds, ethnicity, and experiences. Participants will be
notified of acceptance in June, and classes will begin in September. All deferred applicants are
strongly encouraged to reapply the following year.