ImpACT! Leadership 2023

Application Form

Thank you for your interest in the 2023 ImpACT! Leadership Program.

The program will take place February 3-5, 2023, at the Anaheim Marriott, in Anaheim, CA.

Please provide the following information, and be sure to upload all the required attachments.

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* 1. Name

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* 2. Title

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* 3. Organization

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* 4. Contact Information

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 5. How many years have you worked in the TDM industry?

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* 6. Within your current organization, do you currently have staff reporting to you?

Yes

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* 7. If you have staff reporting to you, please share how many.

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* 8. Which ACT Chapter are you in?

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* 9. Have you participated in other leadership programs (in TDM or any other industry)?

Yes

If "Yes" please specify:

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* 10. To help us gauge interest and ensure that our programs are reflective of our membership, please let us know if you consider yourself to be a member of an ethnic, racial, gender, or other diverse identity:

Yes

Prefer not to answer

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* 11. Professional Resume

Please upload your professional resume

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 12. Personal Narrative

Please upload your personal narrative

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 13. Reference Letter

Please upload your reference letter

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 14. Commitment Form

Please upload your Participant/Employer Commitment Form

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 15. Do you confirm that, if you are selected, you are able to attend the retreat in January; the International Conference July 30-August 2, 2023, in Seattle, WA; as well as participate in pre- and post-virtual events and group projects?

Yes

Thank you for your application. Selected applicants will be notified as soon as possible in the Fall so they can start making travel arrangements.