MLIA Application

Are you ready to grow a leader within your organization? Fill out the below application to be considered for our next kickoff in August. If you have questions about the program please email Jill Ackerman or call 319-377-6316.

MLIA Program Details

MLIA Application

Personal Information:

* Indicates required field

Name *

First

Last

Phonetic pronunciation of name *

Address *

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City

State

Zip Code

Country

Employment:

Current Employer *

Phone Number *

Email *

Business Mailing Address *

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City

State

Zip Code

Country

Type of Business *

Years of Employment *

Title/Position *

Briefly describe your responsibilities *

General Information:

What are you hoping to gain from MLIA? *

What organizations are you already involved in? List positions and responsibilities: *

Employer Authorization:

I have provided program information and received approval from my employer to participate in the MLIA program. I and/or my employer agree to the time and financial commitments required to participate in the program. *

Yes No

Name of Supervisor *

Title/Position *

Application Agreement:

By checking "yes", I agree to fulfill the MLIA course requirements which are session attendance, elective completion and participation and participation in the group project. By checking yes, I understand the $500 ($600 for non-members) is due upon receipt. I also understand that I am personally responsible for any portion of the fee not paid by my employer, and that the fee is non-refundable. *

Yes No

Resume and Professional Headshot

Please attach the following documents below:

Resume *

Max file size: 20MB

Professional Headshot *

Max file size: 20MB

Payment:

Please send invoice to: *

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City

State

Zip Code

Country

Attn: *

Submit