Application Form

It is essential that you answer all questions on this form. We are unable to consider incomplete applications.

Please apply immediately. Limited seats are available.

All information submitted will be held in strictest confidence and used by the Selection Committee only. Submission of this form indicates that both the sponsoring employer and the potential Influence class member have reviewed and accept the program's required commitment of time and financial resources.

	(Bolded fields are required.)
Series applying for:	Select One Influence Focus
First Name:
Last Name:
Title:
Company Name:
Business Address:
City:
State:	Select One ---------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Business Phone:
Cell Phone:
Business Fax:
Business Email:
Home Address:
Home Phone:
City:
State:	Select One ---------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Home E-Mail:
Confirm Home E-Mail:
Number of reporting relationships between you and the senior officer of company
Name of Sponsor:
Title:
Who recommended you for the program?
Previous Influence/Focus persons who nominated you?
Have you applied previously?
	Yes    No
State your education history, including degrees, dates, honors (college, graduate school, professional education):
Give a brief employment history in chronlogical order, starting with your present position.
Organization Dates From/To Title/Position from: to: from: to: from: to:
Annual compensation, including bonus:
	Select One ---------------- Under $39,000 $40,000 - $49,000 $50,000 - $59,000 $60,000 - $69,000 $70,000 - $79,000 $80,000 - $89,000 $90,000 - $99,000 $100,000 - $129,000 $130,000 - $159,000 $160,000 - $199,000 $200,000 - $249,000 $250,000 and over
Indicate your level of competency in each area using a 10-point scale, 10 being the highest:
	Finance Marketing/Sales Information Technology Operations/Production Human Resources Management National/International Trends eCommerce/Internet Self-Managing Teams Learning Organizations Dynamics of Change Management
Briefly describe the critical outcomes expected of your current work position:
List community, civic, business, professional and social organizations in which you are an active member:
The richness of the program is increased and the learning is enhanced when differences in individuals are present. What differences in perspective would you bring?:
What else would you like us to know about you? (Hobbies, family, unique interests, special needs, etc.):
In what ways do you feel this program can serve you?:
It is understood that the nominee, if selected, will be free to attend all sessions of and will not be absent except for critical, unexpected emergencies. This time required will be the Opening Retreat and then five additional two-day sessions spaced throughout an eight to nine month period that ends in May. The Opening Retreat is required for all participants. Tuition for the location is listed here. Some partial scholarships will be available for persons from non-profit, social service agencies. The fee is due upon acceptance into the program. Fifty percent of the tuition is refundable if you cancel prior to August 1. After that, no refund will be allowed. Submission of a completed application indicates you accept these refund terms. Who will pay for your tuition?
	Personally Employer Will apply for partial scholarship assistance
Sponsor (Applications will not be accepted without a sponsor listed.) Applicant Name: Name: Title: Title:     Date:     Date:
Please note: Once your application is received, you will receive an email confirmation from ICAN. IF YOU DO NOT RECEIVE AN EMAIL WITHIN 3 DAYS, please contact ICAN to confirm receipt of your application. All information must be completed. Please re-check this appication for completeness prior to submitting.