Corporate Citizenship Leadership Academy Application Survey

First Name*
Last Name*
Personal Pronouns
(example: she/her/hers; he/him/his; they/them/their)
Title*
Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Please list any dietary restrictions
2. Why are you interested in enrolling in the Leadership Academy for Corporate Citizenship Professionals?*
If you are accepted to this program, are you interested in learning more about post-event coaching? (Leadership Academy participants may request a series of virtual, Zoom-based, 1:1 coaching sessions. Coaching will focus on message discipline and influencing stakeholders. Cost: $5,000.)*
3. Have you previously earned one of our certificates?
Certificate in Community Involvement Management

YesNo
Certificate in Corporate Citizenship Practice*

YesNo
Certificate in Corporate Citizenship Management*

YesNo
Certificate in Corporate Citizenship and Sustainability Reporting*

YesNo
4. Please describe your CURRENT role. What are your key responsibilities?*
5. Please provide a brief background regarding your work experience prior to your current role. What other positions have you held in your current company? What other organizations have you worked for and in what capacity?*
6. How many years have you worked in the corporate sector?*

Less than 3 years3-5 years6-10 years11-15 years16-20 yearsMore than 20 years
7. How many years have you had direct corporate citizenship responsibilities?*

Less than 3 years3-5 years6-10 years11-15 years16-20 yearsMore than 20 years
8. Which of the following statements best describes your scope of responsibilities?*

I have local or facility level responsibilitiesI have regional level responsibilityI have national or business unit level responsibilitiesI have global level responsibilities
9. To whom do you report?*
10. How many people report to you (include direct reports and their direct reports)?*

None1 – 56 – 101 – 1516 – 2021 – 25More than 25
11. Please describe several corporate citizenship related challenges that you are facing right now or on the near horizon that will draw on your skills and abilities as a leader. These could be internal or external challenges.*
12. If applicable, please note any other leadership oriented professional development you have participated in within the last five years.*
13. Please feel free to provide any additional information that YOU feel will help us better understand and assess whether the Leadership Academy is a good fit for you.
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