EMPLOYER AUTHORIZATION FORM

EMPLOYER AUTHORIZATION FORM

NFBPA - Executive Leadership Institute
NAME OF APPLICANT *

First Name Middle Name Last Name Suffix
NAME OF SUPERVISOR/AUTHORIZER *

First Name Middle Name Last Name Suffix
ORGANIZATION/AGENCY/DEPARTMENT *
WORK ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMAIL ADDRESS *
example@example.com
PHONE NUMBER *
Please enter a valid phone number.
CERTIFICATION
I certify that:
- My agency/department/organization understands the financial and time commitments associated with the National Forum for Black Public Administrators Executive Leadership Institute.
  - Tuition - $11,000
  - Time Commitment:
    
    December 2022
    
    1 Virtual Orientation (2 hours)
    
    January 2023
    
    1 Virtual Session (16 hours/2 days)
    
    1 Leadership Coaching Session (1 hour)
    
    February 2023
    
    1 Virtual Session (16 hours/2 days)
    
    1 Virtual Learning Exchange (6 hours)
    
    1 Leadership Coaching Session (1 hour)
    
    March 2023
    
    1 Virtual Session (16 hours/2 days)
    
    1 Leadership Coaching Session (1 hour)
    
    April 2023
    
    1 In-Person Session (32 hours/4 days) Virtual Sessions (32 hours)
    
    NFBPA Forum 2023, Minneapolis, MN
    
    1 Leadership Coaching Session (1 hour)
    
    May 2022
    
    1 Virtual Learning Exchange (6 hours)
    
    1 In-Person Session (6 hours)
    
    Graduation Celebration - Georgetown University, Washington, DC.
- I will allow my employee to participate in the Executive Leadership Institute Sessions as they occur and I approve of this professional development opportunity;
- My organization has identified the funding and will remit the funding in full by December 1, 2022.
NAME OF SUPERVISOR/AUTHORIZER *

First Name Middle Name Last Name Suffix
SIGNATURE OF SUPERVISOR/AUTHORIZER *

Clear
TODAY'S DATE *

Month Day Year
Should be Empty:

EMPLOYER AUTHORIZATION FORM

CERTIFICATION