Name of Candidate

emaN ynapmoC

Title/Position

Telephone

Email*

T-Shirt Size

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Statement of Qualification

*E-Mail address must be s candidate ou online leadership and personal assessments as part of the leadership development program.__________________________________________________________

Address

City ZipState

CORNELL UNIVERSITY, ITHACA, NY • JUNE 6 - 10, 2021

DEADLINE AND CANCELLATION POLICY

E X E C U T I V E L E A D E R S H I P D E V E L O P M E N T P R O G R A M 2021

Nominations are accepted on a rolling basis through the deadline, April 16, 2021.The NGA Foundation must receive full payment by the deadline or registration will be automatically canceled.A Cancellation fee of $150 will be applied prior to April 23, 2021, and no refunds, cancellations or transfers to another candidate will be approved a�er that date.In the event that an in-person program is deemed unsafe, participants will have the option to attend the program virtually for a reduced fee.

CORNELL UNIVERSITY, ITHACA, NY • JUNE 6 - 10, 2021

Name

Title

Company

Address

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

City

E ail Business Phone

NOMINATOR INFORMATION (PLEASE TYPE OR PRINT)

PAYMENT INFORMATION (REGISTRATION FEE: $2,850)

CORNELL UNIVERSITY, ITHACA, NY • JUNE 6 - 10, 2021

Credit Card

Card Number Expiration Date

Name on Card

____________________________

__________________________________________________________Authorization Signature

American Express Discover MasterCard Visa

Enclosed is my check for made payable to NGA Foundation.

__________________________ ______ ____________

__________________________ ___________________

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EMAIL MAILExecutive Leadership Development Program

@nationalgrocers.orgNGA Foundation

601 Pennsylvania Ave, NWNorth Building, Suite 375

Washington, DC 20004Phone: 202-938-2570

PLEASE SEND THIS NOMINATION FORM TO:

E X E C U T I V E L E A D E R S H I P D E V E L O P M E N T P R O G R A M 2021