2017 INTER-CITY LEADERSHIP CONFERENCE

Personal Information Sheet

PARTICIPANT INFORMATION

Name: ______DOB: / /

Last FirstMiddle

(AS IT APPEARS ON YOUR FORM OF IDENTIFICATION – MUST BE EXACT FOR TSA CLEARANCE)

Address: ______City/St.: ______Zip: ______

Home Phone: ______Cell Phone: ______

Name you would like to appear on Name Badge: ______

Company Representing: ______Title: ______

EMERGENCY CONTACT INFORMATION

Name: ______

Last First

Relation: ______Phone: ______

ADDITIONAL INFORMATION

Special Diet: ______Handicaps:______

HOTEL ACCOMMODATIONS

Bed Type: □ Double □ Queen □ King

WEDNESDAY NIGHT ACTIVITY

In addition to the Wednesday evening welcome reception, a group will be attending the Pittsburgh Pirates V. Baltimore Orioles baseball game, food and beverage will be included. Please indicate below whether or not you would be interested in attending.

Attending: □ YES □ NO

ACKNOWLEDGEMENT AND RELEASE

The Greater Columbus Georgia Chamber of Commerce (the "Chamber") is sponsoring its 24th Inter-City Leadership Conference to Pittsburg, PA. The undersigned Participant ("Participant") understands that the Chamber is contracting with third parties for transportation, lodging, meals and other activities for the Participants, and therefore shall have no liability for injury, damage, loss, accident, delay or inconvenience arising out of the transportation of Participants, or in providing hotel accommodations, meals or other activities to Participants. The undersigned Participant hereby releases and discharges the Chamber, its employees, agents and representatives from any and all damages, cost, expenses, actions, causes of action and/or suits of any kind or nature rising out of the Participant's attendance at the Conference.

Print Name: ______Signed: ______

Dated this day of ______, 2017

PLEASE RETURN THIS FORM NO LATER THAN August 1, 2017

Greater ColumbusGeorgia Chamber of Commerce

• P.O Box 1200, Columbus, GA 31902-1200 Fax: 706-327-7512

Email :

Contact Maggie Reese at 706-596-7014 if you need additional information.

2017 INTER-CITY LEADERSHIP CONFERENCE

PARTICIPANT GUIDE INFORMATION

In an effort to better introduce you to your peers on our 24th Inter-City Leadership Conference to Pittsburgh, the team at the Chamber will be putting together an interactive guide highlighting each attendee on the trip. In order to assemble bios for each attendee, we need the attendee to complete the questionnaire below and return to Maggie with a .jpg or .png of your most recent headshot.

**If a questionnaire is not returned by August 1st, the attendee will only have their name and company listed in the trip guide.

QUICK FACTS:

Twitter Handle: @______

  • In 2-3 sentences, please explain your current role and how long you have been with the company you are representing.
  • In 1-2 sentences, please explain what you are hoping to receive or knowledge you hope to gain from participating in our 24th ICLC.

BIO Examples:

Amy Bryan

@AmyAskewBryan

Greater Columbus Ga Chamber of Commerce

Amy Bryan is the Executive Vice President of Community Development & Growth at the Greater Columbus Chamber of Commerce. In her 9th year at the Chamber, Amy oversees the Membership Department, the Leadership and Young Professionals programs as well as planning Inter-City Leadership Conference. Amy has been involved in supporting the conference since starting at the Chamber but is in her fourth year overseeing the trip. Amy sits on various boards and commissions through her work at the Chamber including, the community branding committee, enterprising culture committee and several other Columbus 2025 committees. She also serves on the Mayor’s Commission on Unity, Diversity and Prosperity and many other boards and commissions. Amy hopes to bring back the tools Pittsburgh has used to become the 6th best city for Business Development and Growth and align them with the Chamber’s vision for Columbus 2025.

William Burgin

@wjburgin

Jackson Burgin, Inc.

Will Burgin is President of Jackson Burgin a commercial property development and management company. He has been in that position since 2000 and shortly thereafter began the Village on 13th project, a highly regarded neighborhood retail redevelopment project in Midtown, the historic first-ring suburb of Columbus. Since then, he has continued his focus on the successful regeneration of Midtown through professional as well as volunteer efforts. Presently, Will serves as President of Historic Columbus, a board member of the Community Foundation of the Chattahoochee Valley, a board member of the Greater Columbus Georgia Chamber of Commerce, serves on the Friends of the Dragonfly Trail system committee, special projects committee for MidTown Columbus to include both Minimum Grid implementation as well as Columbus’ approach and support to incremental development, and is Cubmaster for Cub Scout Pack 1 based out of St. Paul United Methodist Church. Additionally, Will is the chairman of this 2018 ICLC Trip.

Will is excited to attend this year’s ICLC trip because Pittsburg has made a successful transition from Steel City to Technology Hub based around 'The White Paper' written as a wake-up call in the mid-90s. This trip should inspire participants for us to not only use the information found in the Regional Prosperity Initiative as a basis for future decisions, but to fundamentally support the efforts of those leading the Columbus 2025 effort.