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* 1. Name

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* 2. Preferred Name (preferred)

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* 3. What is your college?

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* 5. What is your mailing address?

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* 6. What is the name of the department you chair?

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* 7. I have served in the department chair role for:

For questions 8 - 11, please limit your responses to 200 words or less.

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* 8. Describe your department. (For example, what are some of its strengths and challenges? A little about the personalities, etc.)

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* 9. Identify one aspect of your department where you see the potential to make a positive change as a leader.

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* 10. What skills or knowledge areas do you hope to develop through participating in this program?

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* 11. What should the program leaders know about you and how you learn best?

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* 12. Which cohort would you like to participate in? (While it is possible to occasionally attend the other meetings, in the spirit of community building, participants should commit to one cohort)

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* 13. Is there anything else we should know?

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