APPLICATION FOR IGMT 2018-2019 PROGRAM YEAR

Please indicate your choice of accommodations/program fee:

TYPE OF ROOM	PROGRAM FEE	INDICATE CHOICE OF ROOM/ PROGRAM FEE
Private Room	$1,250
Double Occupancy Room	$1,100

NOMINEE INFORMATION
Full Name:
Organization:
Title:
Phone Number:
Address:
Email Address:
Description of position:
Description of experience in leading or managing teams:

IMMEDIATE SUPERVISOR’S INFORMATION (FOR NOMINEE)
Full Name:
Title:
Phone Number:
Email Address:
Briefly state the agency’s objectives and reasons for submitting this nomination:

SUBMITTED BY
By submitting this application, I understand that I am committing this nominee to all of the time and effort required to actively participate with their planning group and to attend all six sessions of IGMT for the 2018-2019 Program year.
Full Name:
Title:
Phone Number:
Email Address:
Signature: (enter full name)