Nomination Form

NEPHLI APPLICATION

All fields marked * must be completed.
Please follow all instructions carefully.

SECTION I. APPLICANT AND EMPLOYER INFORMATION
1.	Name:	*
2.	Agency/Organization:	*
3.	Employment Status:	*
4.	Job or Volunteer Title:	*
5.	Your Work Address:	*
6.	Is your agency/organization willing to contribute toward your tuition costs?	*
7.	Work Telephone No.:	*
	Work Fax No.	*
	Work E-mail Address:	*
	Home Telephone No.:	*
8.	Highest Degree Completed:	*
9.	Gender:	*
10.	Are you a member of your State's public health association?	*
11.	Race or Ethnicity (Optional):	* * Other race:
SECTION II. PERSONAL PROFILE Please email an electronic copy of your resume or curriculum vitae. Alternatively you can fax or post a hard copy, details here. SECTION III. STATEMENT OF PURPOSE* Please write in 300 words or less what you hope to gain for yourself and your organization as a NEPHLI Scholar.
SECTION IV. SCHOLAR COMMITMENTS As an applicant to the Northeast Regional Public Health Leadership Institute, I am willing to make the following commitments if accepted as a NEPHLI Scholar. Further, I understand that if I do not fulfill these commitments, my continued participation in the Northeast Regional Public Health Leadership Institute will be reviewed by the Advisory Committee. 1. I will commit the time necessary to attend all Institute activities including all retreats and completing a Scholar project. 2. I will be an active contributor to the Institute and participate in a team-based learning community. 3. I will fulfill all learning projects required by the program. 4. I will participate in the evaluation of the Institute 5. I agree to allow pictures of me taken during the Institute or alumni activities to be used in NEPHLI publications or displays.
Applicants will need to fax or post a hard copy with their signature, and a supporting signature from a supervisor. The form can be found here. To be completed and signed by the applicant: I have read the required conditions of Scholars of the Northeast Regional Public Health Leadership Institute. I agree to all of the requirements described above.
	* Signature (type name):
	* Date:
SECTION V. ORGANIZATION COMMITMENTS Both Sections A and B should be completed if the applicant has received the relevant permission from their supervisor and/or president or treasurer of the applicant's sponsoring organization. Please dont forget to fax or post a hard copy with the relevant signatures. A. As the immediate supervisor of (type candidates name) * , I have read the Scholar Commitments and agree to allow him or her time off from assigned duties to attend all sessions of the year-long leadership program.
	* Signature: (type supervisor/ president/ treasurer's name)
	* Date:	* Title:
B. I agree to support the applicant by authorizing my agency or organization to contribute to the tuition and transportation costs associated with his or her participation in the Northeast Regional Public Health Leadership Institute.
	* Signature: (type supervisor/ president/ treasurer's name)
	* Date:	* Title:

Supporting signatures may be:

Faxed to 518/402-0305
Mailed to Northeast Regional Public Health Leadership Institute, School of Public Health, One University Place, Rensselaer, New York 12144-3456

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