Leadership AV application First Name* Last Name* Street Address* Address Line 2 City* State / Province* ZIP / Postal Code* Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePhone*Email* Alternate Email Present University or Institutional affiliation* Do you have a passport or Nexus Card for travel into Canada?* Yes No Area of study & Current GPA* Degree expected* Bachelors Masters Doctorate Other Date degree will be granted (Month/Year)* Please provide a description defining your current leadership style and your expectations of how your style might be enhanced by your participation in the Leadership AV Program.*Provide a list of community/volunteer activities that have contributed to your leadership development. Include titles and accomplishments.*What Are Your Career Goals After Graduation?*Availability*Academic References (include name, email and phone number)*Personal References (include name, email and phone number)*Statement of understanding of the conditions of participation in the Leadership AV Program.I understand that, should I be accepted into the Leadership AV Program at Exertis, the following conditions will apply: Passports and Visas: I am responsible for obtaining necessary passport and visas when required. Exertis will issue only a letter stating acceptance of an individual into the program and the conditions governing the program. Confidentiality and Publication of Information: As a participant, I will respect the confidentiality of information that I collect or am exposed to at Exertis. No reports or papers may be published based on information obtained from Exertis without the explicit written authorization of the president and chief operating officer. Although not considered a Exertis employee, I shall be subject to the authority of my Leadership AV Mentor. I understand that I am not entitled to the privileges and benefits accorded by Exertis, its officials and staff members. The Leadership AV Program is not connected with employment and there is no expectancy of such. However, participants can apply for posts advertised externally & internally to Exertis staff after the program is completed. Two to four participants will be selected to participate in InfoComm to be held in one of two locations, Orlando, Florida or Las Vegas, NV. These selections will be made based on program participation and will be made at the sole discretion of the CEO and president of Exertis USA. ATTENDANCE/PARTICIPATION: Full attendance at all sessions is required. Only one absence will be allowed for academic/work situations. Signature*Date* Printed Name* CAPTCHACommentsThis field is for validation purposes and should be left unchanged.