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2. Credentialed Government Leader Program
4. 
6. First Name*
7. Last Name*
9. Job Title*
10. Organization*
12. Office Street Address*
14. City*
15. State
16. Zip*
18. Office Phone*
19. Office Fax
21. Office Email*
22. How long have you worked in local government?*
24. MMASC / MMANC Member?*

    1. Yes

    1. No
25. ICMA Member?*

    1. Yes

    1. No
29. Describe your current responsibilites*
31. Describe your organization (# of employees, annual operating budget, function or services provided)*
33. List your professional honors, awards, and/or volunteer activities*
35. Why do you want to participate in the CGL program and how will it benefit your career growth?*
37. Please describe your career goals*
39. Are you paying for the CGL Program out of personal funds or through your organization/agency?

    1. Paid with personal funds
    2. Paid for by organization
41. Please upload your current resume*
43. Your application will be submitted to the CGL program administrator for review. You will receive a response within 10 business days following receipt of your application. Once accepted into the program, you will be invoiced the $75 entry fee.
    
    I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for dismissal from the program. *

    1. I understand and agree

    1. I do not agree
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

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