Impact Agents of Change™ Training Cohort

Impact Agents of Change™ Training Cohort

Application Form - Illinois Black Chamber of Commerce®
SECTION 1: APPLICANT INFORMATION
Full Legal Name*

First NameLast Name
Preferred Name (if different)
Mobile Phone Number*
Format: (000) 000-0000.
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 OwnerAspiring EntrepreneurInvestorReal Estate ProfessionalNonprofit LeaderCorporate ProfessionalOther
Business Name (if applicable)
Industry / Sector
How long have you been operating your business (if applicable)?

Not yet launchedLess than 1 year1–3 years4–7 years8+ 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?

YesYes, with advance notice for conflictsNo
How would you describe your level of commitment to personal and professional growth? Linear Scale (1–5)

1

2

3

4

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 – $997Non-Member – $1,497Interested in Payment PlanInterested 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?
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

MonthDayYear
Date
Should be Empty:

Impact Agents of Change™ Training Cohort

SECTION 1: APPLICANT INFORMATION

SECTION 2: BUSINESS & PROFESSIONAL BACKGROUND

SECTION 3: INTENT & IMPACT ALIGNMENT

SECTION 4: READINESS & COMMITMENT

SECTION 5: TUITION & ACCESS

SECTION 6: CREDENTIALING & AGREEMENT

SECTION 7: CERTIFICATION & SIGNATURE