<p> EXPLORING LEADERSHIP APPLICATION FORM</p><p>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</p><p>First Name: ______Last Name: ______</p><p>Job Title: ______Supervisory____ Non-Supervisory ____</p><p>Fed Agency: ______Office/Bureau: ______</p><p>Office Address: ______</p><p>Phone: ______Fax: ______</p><p>Email: ______Supervisor’s Email: ______</p><p>Supervisor’s Phone Number: ______</p><p>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.</p><p>Approved by: ______Date: ______</p><p>Title: ______Telephone: ______</p><p>If you have any questions, please contact the Sandy Bruner, [email protected]; (703) 648-5764</p>