African American and African Studies Community Extenstion Center.

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The Ray Miller Institute for Change & Leadership

“Being the change you wish to see”

Fall 2008 Application Form
(Please Note: Neither handwritten applications nor those submitted by e-mail will be accepted)

Name: ______________________________________________________________
            First                                       Middle                               Last

Address: ______________________________________________________________

City: __________________________ State: ______ Zip Code: ________________

Phone 1: ( ) _____________________ Phone 2: ( ) _________________________

Fax: ( ) _________________________ Email: _______________________________

Education:
Current employer: _____________________________

Position Title: _______________________________________

Age: ___________________ Referred by (if applicable): _____________________________________________

Referral’s Phone: ( ) ____________________ Email: ________________________

Please include the following with your application on seperate sheets of paper: Place your full name on each sheet submitted.

1. What does leadership mean to you and why do you wish to participate in The Ray Miller Institute for Change and Leadership? (100 words or less)
2. What are your professional goals for the next 3-5 years? (100 words or less)

Please submit all materials by 5pm on August 29, 2008 to:
African American and African Studies
Community Extension Center
905 Mount Vernon Avenue.
Columbus, Ohio 43203
Subject: The Ray Miller Institute

Your Partner in Education

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