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* 1. Contact Information

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* 2. Social Media:
We would like to connect with you on Social Media.  Please add URL(s) or Handle(s).

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* 3. Please indicate your area(s) of expertise.
(Check all that apply)

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* 4. Are you currently serving on any community or public board(s)?
If yes, please indicate the position(s) you currently hold.

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* 5. What do you hope to gain from the leadership academy?

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* 6. Please tell us what leadership qualities you feel you already possess.

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* 7. What professional and personal goals are you looking to achieve through this program?

Academy Acknowledgement:
Are you willing to commit to the homework and openness needed to make this experience rewarding? If so, please proceed by completing the final step!

I understand that if UnitedAg selects me as a candidate qualified to participate in the Leadership Academy for the 2017 calendar year, I will commit for the one-year program. I also understand that registration fees are non-refundable and non-transferable.

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* 8. Signature (Please initial):

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