Bryan Bell Metropolitan Leadership Forum 2017
NOMINATION FORM
Since 1968, the Bryan Bell Metropolitan Leadership Forum has sought to identify emerging community leaders and stimulate their interest and involvement in community service. Drawing from all sectors – business, faith, nonprofit, neighborhood and civic groups – the Forum provides information about, analysis of and opportunities to explore key metropolitan issues and needs. More information may be found at www.cbno.org.
The Person being nominated should complete this form. Self-nominations are acceptable. Nominations must be received by close of business, Monday, July 24, 2017. Space in the Forum is limited.
PERSONAL
Name of Nominee
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Parish
Your answer
Home Phone
Your answer
Office Phone
Your answer
Other Phone
Your answer
Fax
Your answer
Email Address
Your answer
Date of Birth
MM
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DD
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YYYY
Length of Residence (Metro area)
Your answer
The Bryan Bell Metropolitan Leadership Forum strives to attain diversity on all levels in each class. Your response to the following optional questions will assist us in reaching this objective:
Gender
Ethnic Background
HIGHEST EDUCATION EARNED
Institution
Your answer
Diploma/Degree
Your answer
Date (Month and year)
Your answer
EMPLOYMENT
Please check a category that best describes your current employment
Present Employer
Your answer
Employment Start Month and year
Your answer
Title
Your answer
Since (if different from start date)
MM
/
DD
/
YYYY
Address
Your answer
City
Your answer
Zip
Your answer
AFFILIATIONS
List community, civic, business/professional and/or social organizations that you are or have been affiliated with and any positions held:
Your answer
DESCRIBE YOUR AREAS OF CIVIC CONCERN AND INTEREST
Your answer
AWARDS AND HONORS. List leadership positions, awards and/or honors you have received personally or professionally:
Your answer
PERSONAL PERSPECTIVE. Space in the Leadership Forum is limited. Please describe briefly why you should be selected for inclusion in this year’s Bryan Bell Metropolitan Leadership Forum
Your answer
How did you hear about BBMLF
Your answer
Name of Nominator (if other than nominee)
Your answer
Company (if applicable)
Your answer
Address
Your answer
City
Your answer
Zip
Your answer
Home Phone
Your answer
Business Phone
Your answer
Fax
Your answer
Nominator Email
Your answer
E-Signature
Your answer
Date
MM
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DD
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YYYY
For questions about the nomination form, contact Keith Twitchell at (504) 267-4666. Please note that there is a $300.00 participant fee. Nominees who are accepted for the 2017 BBMLF will be notified as to the timing and methods for paying the participant fee.
53rd FORUM - A LEGACY OF LEADERSHIP
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