PLEASE TYPE OR PRINT

DESCRIPTION OF YOUR PRESENT

RESPONSIBILITIES

BRIEF DESCRIPTION OF YOUR ORGANIZATION

number of employees, annual operating budget, function

or service provided, etc.

PREVIOUS EMPLOYMENT HISTORY

in reverse chronological order

Mr. Ms.

Last Name First Name MI

Preferred Name Date of Birth

Title Organization

O ce Address

City State Zip

O ce Phone Cell Phone Fax

Email Years in Current Position

Name of Organization Title/Position Dates: From–To

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You may download a printable version of this form from our website: http://sei.coopercenter.org/

2018

LEAD/ SEI Application

LEAD Dates SEI Date

July 15-27, 2018

Applications for SEI are due June 1st

Select program preference

EDUCATIONinclude intensive management

development programs

WHY DO YOU WANT TO PARTICIPATE IN

LEAD / SEI?

MYERS BRIGGS

ACCOMMODATIONS

POLO SHIRT SIZE

SIGNATURE OF APPLICANT

FEES

DISCOUNTS

REFUNDS & CANCELLATIONS

DEADLINES

EMAIL TO

Institution Degree/Program Dates: From–To

Are you familiar with the Myers Briggs Type Indicator? No Yes Type _____________

All rooms are non-smoking

Small Medium Large X-Large XX-Large

Signature of Applicant Date

The fee below include the cost of instruction,all materials, most meals, and housinag. Unless prior arrangements have been made, fees are due one month before the start of the program.

A 10% discount is granted to any participant from a Virginia locality that is a member of the Virginia Institute of Government. Virginia Institute of Government Member; Yes No

A 50% fee will be assessed for cancellations within two weeks of the beginning of the program. Substitutions, acceptable to LEAD/SEI, may be made up to two weeks before the start of the program.

Please tell us how you heard about LEAD / SEI.

Name Title

Locality

Other

Payment is due 1 month before the start of program.

Molly HarlowSEI Program Coordinatormjh3a@virginia.edu

Carmie Rodriguez, LEAD Program Coordinatorcarmie@virginia.edu

P.O. Box 400206 • Charlottesville, VA 22904-4206434/987-0331 • Fax: 434/982-5524 • TDD: 434/982-HEAR

LEAD fees are $4,450. SEI fees are $8,100.

SEI application due June 1st. LEAD application due 8 weeks prior to the program.