Bryan Bell Metropolitan Leadership Forum 2018
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 23, 2018. A $50.00 application deposit is required prior to the deadline and will be applied to Forum participation fee of $300.00. Space in the Forum is limited.

Basic Background
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 (Cell) *
Your answer
Fax
Your answer
Email Address *
Your answer
Date of Birth *
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Length of Residence (Metro New Orleans area) *
Your answer
Demographic Information
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)
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Address *
Your answer
City *
Your answer
Zip *
Your answer
Affiliations, Awards & Distinctions
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 the Bryan Bell Metropolitan Leadership Forum? *
Your answer
Nomination Information
Self-nominations are acceptable, but if someone else is tendering your nomination, please complete the following:
Name of Nominator (if other than nominee)
Your answer
Company (if applicable)
Your answer
Address
Your answer
City
Your answer
Zip
Your answer
Business Phone
Your answer
Home or Other Phone
Your answer
Fax
Your answer
Nominator Email
Your answer
Application Submission
Please note that there is a $50.00 application deposit, that will be applied towards the $300.00 participant fee. You may use the PayPal button provided upon submission of the application to complete this payment. If paying via check, the deposit is due before the close of business on Monday, July 23, 2018. In the event that the nominee is not selected to participate in the 2018 Bryan Bell Metropolitan Leadership Forum, this deposit will be refunded. For more information, contact Keith Twitchell at (504) 267-4666.
E-Signature
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Date
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54th Forum - A Legacy of Leadership
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