UnitedAg - 2017 WomenAg Leadership Academy - Application & Questionnaire

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* 1. Contact Information

Name *

Company *

Title *

Address *

City *

State *

Zip Code *

Home Address

Email Address *

Phone Number *

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* 2. Social Media:
We would like to connect with you on Social Media. Please add URL(s) or Handle(s).

I have a LinkedIn Account - URL:

I have a Twitter Account - Handle:

I have a Facebook Account - URL:

Other Digital Media Outlets:

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* 3. Please indicate your area(s) of expertise.
(Check all that apply)

Business

Finance

Education

Public Relations & Media

Marketing

Sales

Health

Legal

Legislative

Foreign Trade

Labor

Volunteer

Other (please specify)

Questionnaire

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* 4. Are you currently serving on any community or public board(s)?
If yes, please indicate the position(s) you currently hold.

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* 5. What do you hope to gain from the leadership academy?

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* 6. Please tell us what leadership qualities you feel you already possess.

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* 7. What professional and personal goals are you looking to achieve through this program?

Academy Acknowledgement:

Are you willing to commit to the homework and openness needed to make this experience rewarding? If so, please proceed by completing the final step!

I understand that if UnitedAg selects me as a candidate qualified to participate in the Leadership Academy for the 2017 calendar year, I will commit for the one-year program. I also understand that registration fees are non-refundable and non-transferable.

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* 1. Contact Information

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* 2. Social Media:We would like to connect with you on Social Media. Please add URL(s) or Handle(s).

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* 3. Please indicate your area(s) of expertise.(Check all that apply)

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* 4. Are you currently serving on any community or public board(s)?If yes, please indicate the position(s) you currently hold.

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* 5. What do you hope to gain from the leadership academy?

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* 6. Please tell us what leadership qualities you feel you already possess.

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* 7. What professional and personal goals are you looking to achieve through this program?

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* 8. Signature (Please initial):

* 2. Social Media:
We would like to connect with you on Social Media. Please add URL(s) or Handle(s).

* 3. Please indicate your area(s) of expertise.
(Check all that apply)

* 4. Are you currently serving on any community or public board(s)?
If yes, please indicate the position(s) you currently hold.