First Name:  
Last Name:  
Home Address:  
Zip Code:  
Daytime Phone:  

Evening Phone:

E-mail Address  
Employer Address  
Employer City:  
Employer State:  
Employer Zip:  
How many years of work experience do you have?  

Statement of Interest - Please respond to the following questions. Your response should be 2-4 word processed pages.

 Why are you interested in being a part of this program?


 How do you define leadership? What leadership qualities do you offer?


 What do you think it takes to be a successful African-American leader?


 What are the greatest leadership challenges and opportunities for southeastern Wisconsin? 


 What is a key area of growth that you would like to focus on through this program?

How did you hear about the program?
Does your employer support your participation in the program?


Name of supervisor or employer contact?
Supervisor's Daytime Phone  
Supervisor's Email Address  


Along with this application, please also email your resume to