NC PHLI Application Form

Please follow the instructions below to complete the application for the second cohort of the North Carolina Public Health Leadership Institute (NC PHLI). Completion of this application indicates that you have read the description of the NC PHLI (posted at: are able to make the time commitment needed for the program.

Please complete all of the following questionsand attach a copy of your current CV/resume.Applications are due by 5 pm on January 26, 2018.

Applicants will be notified by February 5, 2018about acceptance into the program. If accepted, applicants will be sent a link to formally register for the program; registration and payment of a $425registration fee are due no later than March 5, 2018 for all accepted applicants.

  1. Name

Last Name ______

First Name ______

  1. Contact Information:

Organization/Agency: ______

You current public health program area within your agency: ______

Current Job Title/Role: ______

Mailing Address: ______

County: ______

Email: ______

Phone: ______

  1. Demographic Information

Degree(s) (MPH, BSN, etc.)______

Gender (drop down responses/check boxes) ______

Race (drop down responses) ______

Age (drop down ranges provided) ______

  1. How long have you been employed in your current position?
  1. How long have you been employed in public health?
  1. Do you have any public health management experience? If so, in what capacity and for how long? (Preference will be given to applicants with at least 2 years of public health management experience.)
  1. Are you a member of NCPHA? If so, for how many years?(NCPHA membership is not a criterion for acceptance, but 2 years membership in NCPHA is preferred. If you have held any leadership roles within NCPHA, please list.)
  1. Why do you want to participate in the NC Public Health Leadership Institute,and what do you hope to gain or accomplish from your participation? (Please respond in 3-5 sentences.)
  1. Please list any public health leadership development programs you have previously participated in and when. (If not applicable, please note N/A.)

Signatures

Your signature below indicates that you are able to make the 1-year time commitment required by the program.

Applicant Signature: ______

Date: ______

Supervisor signature below denotes understanding that the NC PHLI program is a 1-year commitment for the employee and includes willingness to support the $425 application fee if the employee is accepted plus support for travel costs to attend 5 in-person events.

Supervisor Signature: ______

Title: ______

Date: ______