Fill - Free fillable Enrollment Application (Constant Contact) PDF form

Enrollment Application

Date_______________________

Name _______________________________________________________________________________

Last First Middle

Male ________ Female ________ E-mail Address __________________________________________

Home Address _________________________________________________________________________

Number Street City Zip Code

Business Address _______________________________________________________________________

Number Street City Zip Code

Home Phone ____________________________ Business Phone _________________________________

Cell Phone ______________________________ Food Allergies: ________________________________

Length of Residence in Permian Basin (cumulative) ____________________________________________

If Married: Spouse’s Name _______________________________________________________________

Num

ber of Children (optional) ________ and Names & Ages ____________________________________

______________________________________________________________________________________

Hobbies (optional) ______________________________________________________________________

Employment/Occupation

Account for all periods including military active duty.

Present Employer ___________________________________ Date Began__________________________

Present Title or Responsibility __________________________ Since (date) ________________________

Previous Employment (in Reverse Chronological Order):

Employer Title or Responsibility From To

_______________________ ___________________ _________________ ______________

Continued *

What have you accomplished in your employment/occupation that you think is important?

________________________________________________________________________

Education

Begin with High School, then College(s), Graduate Schools, Business or Trade Schools and/or other

Specialized Training.

Name and Location of School Dates From-To Degree/Certificate Area of Interest

_________________________ _____________ ________________ _____________

Community Activities

List key community, civic, professional, business, religious, social, and other organizations of which you

have been a member within the past five years.

Organization Approximate Dates of Membership Official

Positions

Held

_____________________ ______________________________ ___________

Special Honors or Awards for Leadership Activities __________________________________________

______________________________________________________________________________________

What have you accomplished in these activities that you think is important?

______________________________________________________________________________________

Motivation

1. How would you like to further your long-term nonprofit career?

______________________________________________________________________________________

2.

W

hat skills do you hope to gain from the Nonprofit Executive Leadership Certification

program?

______________________________________________________________________________________

Commitment

Nonprofit Execu

tive Leadership Certification is a learning experience and requires the following

commitments on the part of the participant:

1. Attendance at all 9 sessions (72 hours) is required; therefore, no absences are authorized. Even though

emergencies do arise, participants must complete a minimum of 56 hours to receive certification.

2. A full session shall commence at 8:30 am and end at 4:30 pm.

3. The course work for the Nonprofit Executive Leadership Certification is designed to equip executive

directors or those aspiring to be executive directors with the skills needed for the position. The Board

and/or Executive Director, well as the participant, should understand that a commitment has been made to

attend and actively participate.

Certification will b

e awarded to those who

complete the program by fulfilling the above commitments.

I understand the above commitments and agree to be bound by them in signing this applic

ation.

_________________ _____________________________________________

Date Applican

t’s Signature

______________________________________________________________________________________

Employer Commitment

This application ha

s the approval of this organization and the applicant has our full support, which includes

the time required to participate in the program. Please indicate if self-employed.

_____________________________________________

Organization

_____________________________________________

Signature

_____________________________________________

Title

Upon acceptance to the program the $750 tuition will be billed to the person indicated below:

_____ My organization will be paying for my tuition.

_____ I will be paying for my tuition individually.

Completed Application due by August 7, 2020

Please return to:

Nonprofit Executive Leadership Certification

Nonprofit Management Center

3500 North A Street, Suite 2300

Midland, Texas 79705

432-570-7971

or

Email to sarahl@nmc-pb.org

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Fillable Enrollment Application (Constant Contact)

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