2021 EXECs Advocacy Program Application

Contact Information
Name
First Last
Company Name
Job Title
Email*
Work Phone
Cell Phone*
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tuition and Fees
Tuition and fees for the EXECs Advocacy Program are $2950. Additionally, space is limited to 30 individuals per class. (Limited scholarship assistance is available.) For questions, please contact the EXECs Advocacy Program Manager Priscilla B. Varner, pvarner@cochamber.com.
Nominations
Nominations for the EXECs Advocacy Program must have the support and commitment of a sponsoring business or organization. Please complete below.
Supervisor Name
Supervisor Job Title
Supervisor Phone Number
Supervisor Email
Signature of Applicant
You agree your electronic signature is the legal equivalent of your manual signature on this Agreement
Signature of Applicant*
Date*
Date Format: MM slash DD slash YYYY

Contact Information