GPLI Year 14 Application Demographics Question Title * 1. Applicant Contact Information First Name (of applicant) Last Name Degree(s) Preferred Email Address Phone Number: work Phone Number: cell Mailing Address (for packages) Organization Job Title(s) Question Title * 2. Organization Type Academic Local/County Government State Government Tribal Corporate/Private (for Profit) Community-Based or Non-Profit Hospital, Clinic, Health Delivery Center Federal Agency Other (please specify) Question Title * 3. Supervisor Contact Information (supervisor or person to whom Applicant is primarily accountable) Name Organization Job Title(s) Phone Number E-mail Address Question Title * 4. Applicant number of years in public health or related field 0-1 years 2-4 years 5-9 years 10 years or more Question Title * 5. Applicant number of years in current position 0-1 years 2-4 years 5-9 years 10 years or more Question Title * 6. Do you supervise people? No Yes, how many? Question Title * 7. EDUCATION: Please indicate your education history (in brief) including degrees received. Question Title * 8. EMPLOYMENT HISTORY: Please indicate your employment history (in brief) included up to three previously held positions. Next