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* 1. Contact Information

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* 2. How long have you been in your current role at your organization?

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* 3. Social Media:
We would like to connect with you on social media. Please add URL(s) or handle(s).

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

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

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

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

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* 9. How did you hear about this program?

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* 10. Have you participated in a leadership program previously? If so, please indicate with which organization, when, where, the length of participation and if it was held virtually or in-person.

Academy Acknowledgement:
Are you willing to commit to the assignments, virtual meetings, in-person meetings and travel 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 2023 calendar year, I will commit to the one-year program. I also understand that registration fees are non-refundable and non-transferable.

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* 11. Signature (Please Type):

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* 12. Date

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