Local Government Leadership Intensive

* First Name

* Last Name

Title

Organization/Unit of Government

* Address

Addt'l Address

* City

* State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland & Labrador North Carolina North Dakota Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Not Applicable

* Zipcode

* Day Phone Number

* E-mail If you supply an e-mail address, a receipt for your registration will automatically be sent to that account. An e-mail address is required to pay using a credit card.

* Are you an Alumni of GLLA? If yes, please add the program and year.

* I would like to attend the GLLA Leadership Intensive Program ($95.00)

Special Dietary Needs: If you indicate an allergy, please specify if it's ingested or airborne. Please provide as much information as possible about your restrictions so that we can appropriately meet your needs.

* I learned about the MSU Extension Great Lakes Leadership Academy from   GLLA e-newsletter  Mailed postcard  Local news article  Meeting/Co-worker  Great Lakes Leadership Academy website  Other 

If other source, please identify: