Leadership Academy Application Form

Leadership Academy Application Form

Questions about this application? Contact Jim Lombardo via email at jlombardo@biginy.org or by phone at 315-432-4226.

Applicant Information

Full Name*

Address*

Phone*

Email*

Company Information

Company Name

Company Address

Company Phone

Total Insurance Industry Experience

Company

Job Title

Number of years

Responsibilities

Company

Job Title

Number of Years

Responsibilities

What makes you a good candidate for our Leadership Academy?*

What specific benefit do you want to gain from the Leadership Academy?*

Date

Send me a copy of my responses

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