LEA D E RSHI P 2021 - National Grocers Association
Transcript of LEA D E RSHI P 2021 - National Grocers Association
Name of Candidate
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Title/Position
Telephone
Email*
T-Shirt Size
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Statement of Qualification
*E-Mail address must be s candidate ou online leadership and personal assessments as part of the leadership development program.__________________________________________________________
Address
City ZipState
CORNELL UNIVERSITY, ITHACA, NY • JUNE 6 - 10, 2021
DEADLINE AND CANCELLATION POLICY
E X E C U T I V E L E A D E R S H I P D E V E L O P M E N T P R O G R A M 2021
Nominations are accepted on a rolling basis through the deadline, April 16, 2021.The NGA Foundation must receive full payment by the deadline or registration will be automatically canceled.A Cancellation fee of $150 will be applied prior to April 23, 2021, and no refunds, cancellations or transfers to another candidate will be approved a�er that date.In the event that an in-person program is deemed unsafe, participants will have the option to attend the program virtually for a reduced fee.
CORNELL UNIVERSITY, ITHACA, NY • JUNE 6 - 10, 2021
Name
Title
Company
Address
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City
E ail Business Phone
NOMINATOR INFORMATION (PLEASE TYPE OR PRINT)
PAYMENT INFORMATION (REGISTRATION FEE: $2,850)
CORNELL UNIVERSITY, ITHACA, NY • JUNE 6 - 10, 2021
Credit Card
Card Number Expiration Date
Name on Card
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__________________________________________________________Authorization Signature
American Express Discover MasterCard Visa
Enclosed is my check for made payable to NGA Foundation.
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EMAIL MAILExecutive Leadership Development Program
@nationalgrocers.orgNGA Foundation
601 Pennsylvania Ave, NWNorth Building, Suite 375
Washington, DC 20004Phone: 202-938-2570
PLEASE SEND THIS NOMINATION FORM TO:
E X E C U T I V E L E A D E R S H I P D E V E L O P M E N T P R O G R A M 2021