2018 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

I.General Information

Name Preferred First Name

Title Organization

Business Address Zip:

Business Phone Email

Home Address Zip:

Cell Phone Email

Assistant 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 Alumnae

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

******************************************************************************

APPLICATIONS MUST INCLUDE: 1. AN ORGANIZATIONAL CHART

2. A BRIEF RESUME

******************************************************************************

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 alumnae 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 13, 2018 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)