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CLI Application
Name
*
First
Last
Preferred Name
First
Last
This will be printed on your class name badge
Formal Name
First
Last
This will be printed on your program certificate at completion of course
Phone (Home)
*
If you only have a cell phone, please populate here as well.
Phone (Cell)
*
Email
*
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Are you currently employed?
*
Yes
No
Business Information
Business Name
Business Sector
Accounting
Acquisitions/Dispositions
Architecture
Asset Management
Brokerage
Business Development
Construction
Consulting
Education
Finance
General Management
Government
Health Care
Human Resources
Information Services
Land Use Zoning and Planning
Law
Marketing
Not for Profit
Public Relations
Real Estate Development
Retail
Sales
Technology
Title/Escrow
Job Title
Job Title Category
Account Exec
Accountant
Administrative Asst
Analyst
Attorney
Auditor
Chief
Consultant
Controller/Comptroll
Coord/Administrator
Designer
Director
District/Regional Mg
Division Manager
Engineer
Facilitator
Faculty
General Counsel
General Manager
Health Care Professional
Health System Administrator
Manager
Nurse
Office Manager
Officer/Board Member
Owner
Partner/Principal
Physician
Planner/Developer
Plant Manager
President/CEO/COO
Product Manager
Programmer
Project Manager
Purchasing Agent
Representative
Sales Rep
Scientist/Chemist
Specialist
Superintendent
Supervisor
Technician
Treasurer
Vice President
Miscellaneous
Job Function
Academia
Accounting
Advertising/Public Relations
Audit
Communications
Compen/Wage & Sal/Benefits
Consulting
Contracts
Controller's Office
Corp Strategy/Planning
Credit/Collection
Customer Service
Distribution/Traffic
Employee Relations
Engineering
Environmental
Finance/Budget
General Management
Health Services
Healthcare Services
Human Resource
Int'l Marketing
Internal/Corp Comm
Investor Relations
Labor Rels/Ind Rels
Logistics/Planning
Manufacturing
Marketing
Marketing Research
Materials Mgmt/Inv Control
Medical
Mgmt Info Sys/Dp
New Product Development
Operations Management
Operations/Maintenance
Organization Ping
Personnel
Placement/Recruiting
Product/Brand Mgmt
Production
Project Delivery
Public Affairs/Govt
Purchasing/Procurement
Quality Mgmt/Assurance
Research & Dev
Sales
Technical
Training & Development
Miscellaneous
Business Website
Business Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Education
Please include trade schools and other specialized training and/or education.
Connection to Cape Cod: Years Worked/Lived On Cape Cod
*
Years Working on Cape?
Years Living on Cape?
*
Years Living on Cape?
Program Interest
*
Why do you want to participate in the Community Leadership Institute?
How did you hear about this program?
*
Professional/Personal Achievements
*
What do you consider your highest responsibility, skill or career achievement?
Volunteer Service
*
What community service activities are you participating in?
Do you expect to expand or redirect your volunteer activity upon completion of this course?
*
Please Explain
How do you anticipate that your participation will benefit your community, organization, or work?
*
Professional Reference(s)
Please include their full name, phone, email and your relationship.
Are you available to attend every session?
*
Yes
No
If no, please explain
In the future, are you interested in joining any other Leadership Cape Cod programs, events or committees? Please select all that apply:
Non-Profit Board Leadership
Board Boot Camp
Senior Executive Program
Teacher Program
Alumni Networking Events
Alumni Outreach Committee
Fundraising Committee
Governance Committee
Marketing Committee
Programming/Education Committee
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