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.

*1.Applicant Contact Information(Required.)

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)

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

Name

Email Address

Organization

Job Title(s)

Phone Number

*3.Organization Type(Required.)

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)

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

0-1 years

2-4 years

5-9 years

10 years or more

*5.Applicant number of years in current position(Required.)

0-1 years

2-4 years

5-9 years

10 years or more

*6.Do you supervise people?(Required.)

Yes, how many?

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

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

Current Progress,

0 of 15 answered

Create surveys and forms with ease. Sign up free.

Privacy & Cookie Notice