DMV Diversity & Inclusion Application Email First Name * Last Name * Name You Prefer to be Called Email * Birthdate * Gender * male female Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Phone Number * How did you hear about this program? * Are you an LCE alum? * yes no If yes, please provide the program name and year you graduated: Candidate Employer * Employer Website Current Position/Title * Employer Address Employer City Employer State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming What type of organization is your employer? * Company Foundation Government Non-Profit Organization School Briefly describe your job responsibilities: * Employment History * Beginning with your most recent, please list your employment history. Education and Training * Begin with the most recent. What do you hope to gain from your DMV Diversity and Inclusion Class experience? * Is there anything else you’d like to share about yourself that you feel would be important for the selection committee to know? I understand the mission of Leadership Center for Excellence and the importance of pilot program participation. If selected, I acknowledge the time commitment and will pay tuition by June 21, 2019. If I am unable to comply with the requirements, I will voluntarily withdraw from the program. I understand that in the interest of the class experience for all participants, any participant may be removed from the class if, in the opinion of Leadership Center for Excellence, that participant’s conduct is not conducive to the work of the group. I further understand that tuition is not refundable in whole or in part. Signed (applicant) *
