Advisory Panel on Technology Content - Application

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* 1. Please provide your contact information.

Name: *

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

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* 2. Job Title

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* 3. I am a member of ICMA.

Yes

No

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* 4. Please list activities in which you are involved which help to demonstrate your level of commitment to the local government management profession.

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* 5. Please list any award or recognition you have received that would demonstrate your status as an exemplary leader in service to local government.

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* 6. My employer has approved my participation in this program.

Yes

No

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* 7. I agree to fulfill any post-session requirements as designed by the panel that is intended to contribute to the advancement of leadership, the profession and its body of knowledge. This will include writing an article for use by ICMA in the newsletter and on the website.

Yes

No