Course Date &
Location
* City:
Philadelphia
* Course Date:
November 11, 12 and 13, 2008
December 9, 10 and 11, 2008
January 20, 21 and 22, 2009
February 24, 25 and 26, 2009
April 7, 8 and 9, 2009
May 12, 13 and 14, 2009
July 14, 15 and 16, 2009
September 15, 16 and 17 2009
October 20, 21 and 22, 2009
November 17, 18 and 19, 2009
December 15, 16 and 17, 2009
Personal Information
* First Name:
* Last Name:
Company Information
* Company Name:
* Street Address:
* City/State/Province:
* Zip/Postal Code:
* Country:
* Work Phone:
* Company Fax:
Admin. Assistant's Name:
Assistant's Phone:
* Email Address:
Cellular Phone:
Job Information
How long have you been with the company?
20 years or more
15 - 20 years
10 - 15 years
5 - 10 years
2 - 5 years
1 - 2 years
Less than a year
Current job title/position?
How long held?
20 years or more
15 - 20 years
10 - 15 years
5 - 10 years
2 - 5 years
1 - 2 years
Less than a year
Number of employees under your management?
5000 or more
1000 - 5000
100 - 1000
50 - 100
20 - 50
0 - 20
What budget amount are you accountable for?
100 Million or more
5 - 100 Million
Less than 5 Million
Your manager's name?
Manager's title/position?
Your primary responsibilities?
Job History
Please list your previous job
titles (and company names, if other than this company) during the past 10 years.
Include a brief description of responsibilities and the number of employees under
your management.
Background
Please list any major responsibilities
you have for community activities, volunteer organizations or other non-business
related endeavors.
Education
Please list educational programs
which have had a significant impact on your professional development. Include any
college and university degrees earned, when awarded, and the institution from which
received. Also any teaching positions you hold presently or held in the past.
Participation Objectives
Given what you know so far about
Breakthrough Intensive , what can you commit to accomplishing
in your career and your development as a leader through your participation in the
program? (This will mark the beginning of the conversation which will support you
in achieving your objectives throughout your participation in the program.)
What would you like to contribute
to your organization as a result of your participation?
What aspects of your leadership
would you want to strengthen as a result of your participation?
(*information is required for registration)