Certificate Application

Items marked with an asterisk are required.

Your application will be reviewed on a rolling basis before acceptance into the Supervisory Leadership Certificate, Emerging Leader Certificate, or Women Lead. Certificate Program. You will receive acceptance communication from the UD Center for Leadership and additional program information approx. 30 days prior to the program start date.

Women Lead. Certificate Program

Supervisor Leadership Certificate Program

Emerging Leader Certificate Program

Which program are you applying?

When do you anticipate starting the program? *Please note, Emerging Leader starts twice per year in Jan and Aug. Supervisory Leadership starts six times per year in Jan, March, May, July, Sept., and Oct. Women Lead. starts once a year in March.

First and Last Name:

Your Preferred Name:

Job Title:

Organization (**UDRI employees are asked to please register through Jessica Furderer):

Best Address for Material Mailings (this may not be your work address):

City:

State:

Zip Code:

Email address (please be sure this is an email address you can access outside of work hours, in case of a weather or other emergency):

Mobile Phone number:

Name of person responsible for payment:

Title of person responsible for payment:

Business address of person responsible for payment:

Email of person responsible for payment:

Phone number of person responsible for payment:

Name of Manager

Title of Manager

Email of Manager

Phone number of Manager

List any degrees you have received and the awarding institution:

Briefly state your present job responsibilities, time at the current organization and position, and number of direct reports:

If applicable, list your three previous titles and employers:

Briefly state three of your strengths:

Briefly state three areas that need further development:

In 250 words or less, explain why you want to participate in this program:

My employer will be financing.

I will be financing.

Financing:

Cancellation Policy: If the participant who has been accepted into the certificate program cancels within 14 days prior to the start of the cohort, the seat will still be charged and full payment shall still be due. A substitute participant for that seat is permitted, but additional fees may apply for materials already shipped to the original participant, assessments already completed, etc.

Submit

CONTACT

Center for Leadership

300 College Park
Dayton, Ohio 45469 - 7025

937-229-3115
Email