Exploring Leadership Application Form

EXPLORING LEADERSHIP APPLICATION FORM

Course Name: EXPLORING LEADERSHIP – A MID-LEVEL PROGRAM Dates & Module I: October 31 – November 4, 2016 Washington, DC Location: Module II: January 9 -13, 2017 Albuquerque, NM Module III: March 27 - 31, 2017 Washington, DC

First Name: ______Last Name: ______

Job Title: ______Supervisory____ Non-Supervisory ____

Fed Agency: ______Office/Bureau: ______

Office Address: ______

Phone: ______Fax: ______

Email: ______Supervisor’s Email: ______

Supervisor’s Phone Number: ______

Supervisory Approval: I certify that the above student has received approval, and is available to attend the entire program requested. If there is a cancellation, the Washington Learning Center will be notified at least 10 business days before the scheduled class.

Approved by: ______Date: ______

Title: ______Telephone: ______

If you have any questions, please contact the Sandy Bruner, [email protected]; (703) 648-5764