2017 Greater Philadelphia Leadership Exchange Application
Thank you for your interest in the Greater Philadelphia Leadership Exchange on October 12-13 in Philadelphia! Participation in the Leadership Exchange is a competitive process with a goal of representing the geographic, demographic, sector, and industry diversity of the region. To be eligible, applicants must live or work in the Greater Philadelphia region and serve in a leadership role in a business, nonprofit, or government organization. Completing the application will take around 15 minutes.

2017 registration fees:
- $650 for organizations with annual revenues under $10 million and all government agencies
- $925 for organizations with annual revenues over $10 million

First name: *
Your answer
Last name: *
Your answer
Full name for print materials: *
Your answer
Organization name: *
Your answer
Job title: *
Your answer
Mailing address 1: *
Your answer
Mailing address 2:
Your answer
Mailing address city: *
Your answer
Mailing address state: *
Your answer
Mailing address zip code: *
Your answer
Email address: *
Your answer
Business phone number: *
Your answer
Mobile phone number: *
Your answer
Twitter handle:
Your answer
Assistant name:
Your answer
Assistant phone number:
Your answer
Assistant email address:
Your answer
Organization website: *
Your answer
Organization's total annual revenues: *
Type of Organization *
Organization Sector (select all that apply): *
Required
Have you previously participated in the Leadership Exchange? *
Age: *
We ask only to help us achieve a diverse cohort of emerging and established leaders.
Gender: *
We ask only to help us achieve a diverse cohort.
Ethnicity/Race: *
We ask only to help us achieve a diverse cohort. You may check as many boxes as apply to you.
Required
If you were referred by a friend or colleague, please specify who made the referral:
Your answer
County in which you work: *
County in which you live: *
Briefly describe why you would like to participate in the 2017 Leadership Exchange. *
Your answer
Please provide up to three (3) affiliations you have with other organizations and describe your role. Affiliations include current boards and significant volunteer commitments. *
Your answer
Is there anything else that should be considered in weighing your application?
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Economy League of Greater Philadelphia. Report Abuse - Terms of Service - Additional Terms