Thank you for your interest in EPIP-NY Steering Committee. Please note that if selected, you will be expected to participate in a Steering Committee strategic planning session on Saturday, August 20, 2016 from 12-4 p.m. If you are unable to attend, please indicate so on your application.

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* 1. What is your name?

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* 2. Where are you currently employed?

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* 3. Are you currently an EPIP member?

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* 4. How should we contact you?

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* 5. Please enter the name and email address of the person who will be completing your recommendation.

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* 6. Please indicate your areas of particular interest: (check any that apply)

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* 7. What interests you most about being an EPIP-NY Steering Committee Member?

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* 8. What are some leadership goals you'd like to accomplish during your Steering Committee tenure?

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* 9. In EPIP-NY, we often focus on the importance of leading from where you are. Once voids have been identified, it takes a leader to step up and make the necessary changes. Please describe how you’ve encountered leadership moments in your current role and what your learned about yourself as a leader from this experience?

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* 10. If you had to design an EPIP-NY event, what would it be?

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