2016-2017 Application for Admission Full Name: Preferred Nickname: Home Address: City:
State:
Home Phone:
Cell Phone:
Zip:
Employer: Business Address: City:
State:
Zip:
Business Phone: E-mail Address: Sponsoring Business or Organization (if applicable): I am allergic to the following: I require a special diet as follows: What is your definition of leadership? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
TUITION: The cost of the RDLI Program is $650. Checks should be made payable to the Mt. Pleasant Area Chamber of Commerce. Tuition will be paid by: Me
My Employer
My Sponsor _________________________ (Name of Sponsor)
TUITION PAYMENT SCHEDULE: $100.00 refundable deposit due with submitted application* Full payment is due before class starts.
You will not be permitted to attend orientation or the first class if your payment has not been received. COMMITMENT: Attendance is critical to the success of the Rollie Denison Leadership Institute. Your prompt and complete attendance at the monthly sessions are required for graduation. The signature of your sponsor or employer (if applicable) is required as an indication of support for your participation in the Leadership Institute.
Signature of Sponsor or Employer
Title
Signature of Applicant
Date
DEADLINE: Applications must be dropped off or received by mail at the Mt. Pleasant Area Chamber of Commerce, 113 W. Broadway St. Suite 180, Mt. Pleasant, MI 48858 by Friday, September 23, 2016. Applications may also be scanned and e-mailed to President and CEO Bret Hyble at
[email protected]. If you have any questions, please e-mail Bret Hyble or call him at 989-772-2396.
