Application Form

Important Information

Please note: Attendance is required at all sessions, as each session builds upon the previous. Please ensure you are able to attend all program sessions before you apply.

Series Applying For:

First Name

Preferred Name:

Last Name:

Title (i.e. Director of Marketing):

Company Name:

Business Address:

Business Address 2:

Business City:

Business State

Business ZIP/Postal Code

Business Phone:

Business Email:

Personal Email:

Home Address:

Home City

Home State

Home ZIP/Postal Code

Home Phone:

Cell Phone:

Birthday Date (Month/Day/Year)

Gender:

Who is authorizing/sponsoring your participation in the program?

First Name

Last Name

Title:

Email:

Who is your direct supervisor?

First Name

Last Name:

Title:

Email:

The IMPACT program includes a closing celebration for you and your company sponsor to attend

Are there any dietary restrictions or special accommodations you require?

Please provide your education history

College 1 Information:

Name:

Location (City, State):

Dates:

Degree (i.e. BA, BS, MBA)

Major:

Honors:

College 2 Information:

Name:

Location (City, State):

Dates:

Degree (i.e. BA, BS, MBA)

Major:

Honors:

Please provide a brief history of employment in chronological order, starting with your present position.

Organization 1 Information:

Name:

Dates:

Title:

Organization 2 Information:

Name:

Dates:

Title:

Organization 3 Information:

Name:

Dates:

Title:

Number of years in Supervisory Role:

How many people currently report to you?

Was receiving college credits important to you when you decided to participate in this program?

Please list any leadership or management development programs attended:

Please give a brief description of your career objectives:

Briefly explain why you want to participate in IMPACT:

The richness of the program is increased and learning enhanced when differences in individuals are present. What differences in perspective might you bring?

Have you ever attended an ICAN program?:

Please list ICAN programs you've attended:

Please list community, civic, business, professional and social organizations in which you are an active member:

Will you be using company tuition reimbursement dollars for this program?

Have you previously attended Creighton University?

If you answered yes to the question above, please put your Creightion NetID:

Please provide the last 4 digits of your SSN:

Who would you like your invoice emailed to? (Name, Title, Email, Phone)

Complete the following questions ONLY if you work for a nonprofit organization with 50 employees or less. CLICK HERE to see scholarship opportunities available.

Executive Director:

# of Employees:

Headquarters Location:

Who recommended you for this program?

What are your job accountabilities?:

How long have you been in this position?:

How did you hear about the ICAN Scholarship?:

Web Site:

NAM Member:

Operating Budget:

If you DO NOT wish for your pictures or comments to be used in ICAN promotional materials please check the box.

I UNDERSTAND THAT ALL INFORMATION SUBMITTED WILL BE USED BY THE ICAN, INC. OFFICE ONLY. FACILITATORS PLEDGE ABSOLUTE CONFIDENTIALITY REGARDING INFORMATION CONTAINED IN ALL ASSESSMENTS. I UNDERSTAND THAT SUBMISSION OF THIS COMPLETED APPLICATION INDICATES THAT BOTH MY EMPLOYER AND I HAVE REVIEWED AND ACCEPT THE PROGRAM'S REQUIRED COMMITMENT OF TIME AND FINANCIAL RESOURCES. THE FEE IS DUE UPON ACCEPTANCE INTO THE PROGRAM. FIFTY PERCENT OF TUITION IS REFUNDABLE IF YOU CANCEL PRIOR TO ONE MONTH BEFORE THE PROGRAM START DATE. AFTER THAT, NO REFUND WILL BE ALLOWED..SUBMISSION OF A COMPLETED APPLICATION INDICATES YOU ACCEPT THESE REFUND TERMS.

I accept these terms

Please note: Once your application is received, you will receive an email confirmation from ICAN. IF YOU DO NOT RECEIVE AN EMAIL WITHIN THE NEXT BUSINESS WEEK, please contact ICAN at ican@icanglobal.net to confirm receipt of your application.

Contact Information