Leadership Greater Chicago
Fellows login
* required fields
First name *
Last name *
Date of birth * (ex. 9/14/1970)
My spouse will be a part of the 2008 Leadership Connect Program.
Spouse name
Address line 1 *
Address line 2 *
City *
State * Alabama Alaska Alberta APO Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida FPO Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Foundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia NW Territories Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip *
Date Moved to Chicago Area *
Previous Home location *
Title *
Organization/company *
Work Address *
Suite/Apt # *
Work phone *
Work fax
Work email *
Please describe below the company you work for and your responsibilities in the company.
Please describe below your reason for applying to the Leadership Connect Program; what you hope to achieve from your participation; and how you will utilize the experience.
I agree to take part in the four program segments described in the Leadership Connect Brochure.
I/My Company agree to remit $5,000 for full payment within 30 days of my acceptance to the Program.