Great Plains Leadership Institute Year 20 Application

Demographics

The following components are requested in the online application. It is recommended that you complete essay responses in Microsoft Word, and then copy them into the field available in this application.

NOTE: The system will not save your information. Please be prepared to respond to all questions in one sitting.

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: street, city, state and zip code (for packages)

Organization

Job Title(s)

Question Title

* 2. Supervisor Contact Information (supervisor or person to whom Applicant is primarily accountable)

Name

Email Address

Organization

Job Title(s)

Phone Number

Question Title

* 3. 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

* 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?

Yes, how many?

Great Plains Leadership Institute Year 20 Application

Demographics

Question Title

* 1. Applicant Contact Information

Question Title

* 2. Supervisor Contact Information (supervisor or person to whom Applicant is primarily accountable)

Question Title

* 3. Organization Type

Question Title

* 4. Applicant number of years in public health or related field

Question Title

* 5. Applicant number of years in current position

Question Title

* 6. Do you supervise people?

Question Title

* 7. EDUCATION: Please indicate your education history (in brief).

Question Title

* 8. EMPLOYMENT HISTORY: Please indicate your employment history (in brief) including up to three previously held positions.