Preparing Business and Community Leaders

A program of the Shiawassee Regional Chamber of Commerce, Baker College of Owosso & the Cook Family Foundation

Leadership Shiawassee Confidential Application

Enter the information and click the Submit button. You will then be able to pay the tuition using our secure shopping cart.

Name
Home Address
Home Phone
E-mail Address
Employer
Job Title
Business Address
Business Phone
Business Fax
Employer's E-mail Address
Years in Position
Birth Date
How may years have you lived in the Shiawassee area?
How long do you expect to remain here?	1-5 years 5+Years

Community Involvement

Please list civic, religious, political, professional, social or other activities. Show official positions held.

Sponsoring Employer, Organization, Agency

Name and Title	Address


Candidates recommended by 1996-2006 alumni will receive first consideration.

Motivation

Why are you motivated to take this class?
(One paragraph)

Agreement

I understand the attendance requirements. I will devote the necessary time and energy to complete the program.
I have the cooperation and support of my employer.

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