2017 MOMENTUM Application
Please clearly print or type all answers and complete four page application fully. A pdf version of this form is also available online at www.momentumleaders.org.
I. General Information
Name Preferred First Name
Title Organization
Business Address Zip:
Business Phone Email
Home Address Zip:
Cell Phone Email
Assitant Name ______Assistant Phone ______
Preferred Mailing Address? Home Business
Please check how you learned about the MOMENTUM program:
MOMENTUM Board Member Name:
MOMENTUM Literature _____ Human Resources Department/My organization
Website _____ MOMENTUM Alumni
Newspaper/Magazine/Media Other (please specify)
Ethnicity (optional) check one:
African American Caucasian Hispanic/Latino Native American
Asian/Asian 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 $5,000,000 $5,000,000 to $100,000,000 >$100,000,000
Number of Employees:
<50 50 to 499 500 to 5,000 >5,000
II. Please complete the following questions limiting your replies to space available.
1. Name, address, and phone number of company, organization, and individual nominating you or indicate self-nomination. (Source of nomination will not impact selection decision.)
Name:
Address:
Phone/Fax: Email:
Self-nominated
How long employed by this business/agency? ____
I report to:
Head of Division Board of Directors/Trustees President/CEO of Organization
I own the company Other
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APPLICATIONS MUST INCLUDE: 1. AN ORGANIZATIONAL CHART
2. A BRIEF RESUME
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2. Briefly describe your present job function and responsibilities (include length of time in the organization and in this position).
3. What is the largest size budget you have overseen? ______; Number of FTE’s supervised?__
4. Briefly self-describe your leadership style:
5. Would you agree to your supervisor completing a questionnaire about you? yes no
If so, to whom do you report ?
Name:
Title:
Address:
Fax: Email:
6. How many people currently directly report to you?
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. 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 alumni requirement for MOMENTUM graduates is to become a mentor to a woman or girl or an emerging women’s organization. What thoughts do you have about how you would select someone to mentor and what you might expect to give/receive such a commitment
12. Specifically, what do you hope to gain by attending MOMENTUM?
13. What assessment personality inventory or leadership assessment instruments have you completed in the last five years?
Myers-Briggs
______Dimensions of Leadership Profile
California Psychological Inventory
______Emotional Conflict Inventory (ECI)
A 360 feedback instrument Which ?
Others?
III. Please check appropriate space.
If selected as a participant:
My organization/sponsor is prepared to cover my $4,000 tuition in full.
I will assume responsibility for my tuition in full.
I have financial needs which would make me unable to attend this program and need to be considered for scholarship assistance. Please provide a brief statement explaining why you seek assistance:
I certify that all statements made in this application are true, complete and correct to the best of my knowledge and are made in 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.
If selected, I will remit the tuition fee on or before July 12, 2017 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.
Signature Date Name (please print)