Impact Agents of Change™ Training Cohort
Application Form - Illinois Black Chamber of Commerce®
SECTION 1: APPLICANT INFORMATION
Full Legal Name
*
First Name
Last Name
Preferred Name (if different)
Mobile Phone Number
*
E-mail
example@example.com
City and State of Residence
LinkedIn Profile URL (optional but encouraged)
Website or Business Page (if applicable)
SECTION 2: BUSINESS & PROFESSIONAL BACKGROUND
Current Status (Select one)
Business Owner
Aspiring Entrepreneur
Investor
Real Estate Professional
Nonprofit Leader
Corporate Professional
Other
Business Name (if applicable)
Industry / Sector
Please Select
Professional Services
Real Estate
Construction / Development
Technology
Finance / Investing
Retail / E-commerce
Media / Creative
Nonprofit / Social Enterprise
Other
How long have you been operating your business (if applicable)?
Not yet launched
Less than 1 year
1–3 years
4–7 years
8+ years
SECTION 3: INTENT & IMPACT ALIGNMENT
Why do you want to participate in the Impact Agents of Change™ cohort?
What type of impact do you want to create in your community through business, investing, or real estate?
Which areas are you most interested in developing through this cohort? Business Ownership & Scaling, Access to Capital & Funding, Real Estate Ownership & Development, Investing & Wealth Building, Collective Economics, Community Revitalization, Policy, Advocacy & Leadership, Branding & Media Influence
SECTION 4: READINESS & COMMITMENT
This is a 10-week in-person cohort held Saturdays from 10:00 AM – 12:30 PM. Are you able to commit to attending all sessions?
Yes
Yes, with advance notice for conflicts
No
How would you describe your level of commitment to personal and professional growth? Linear Scale (1–5)
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Are you willing to actively engage with cohort members, instructors, and guest experts? Yes/No
SECTION 5: TUITION & ACCESS
Tuition Options (Select one):
Chamber Member – $997
Non-Member – $1,497
Interested in Payment Plan
Interested in Scholarship (limited availability)
If requesting a scholarship or payment plan, briefly explain your request:
SECTION 6: CREDENTIALING & AGREEMENT
Upon completion, participants will receive a Graduate Certificate and Impact Agent of Change™ Award. How do you plan to leverage this credential?
How did you hear about this program?
Please Select
Illinois Black Chamber of Commerce
Chamber Email
Social Media
Referral
Website (ilbcoc.org)
Other
SECTION 7: CERTIFICATION & SIGNATURE
Applicant Certification (Checkbox)
I certify that the information provided is accurate and complete. I understand that acceptance into the Impact Agents of Change™ cohort is selective and based on alignment, readiness, and availability.
Signature
Date
-
Month
-
Day
Year
Date
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