Portland State University

Program Application

Personal Information
First Name*
 Middle Name
 Last Name*
Street Address*
 City*
 State*
 Postal Code*
Email Address*
 Phone
 Dietary Restrictions

 

Professional Information
Company Name*
 Position*
Street Address*
 City*
 State*
 Postal Code*
Work Email Address*
 Work Phone*
 Work Fax
Years in Current Job*
 Years in Managment
 Number of People you Manage

 

Please provide a brief description of your job responsibilities*

 

Please provide a brief description of your company's products or services

Supervisor's Name*
 Supervisor's Job Title*
 Supervisor's Phone Number*
Supervisor's Address
 City
 State
 Postal Code

 

If an individual in your company selected you for this program, please provide the following:
Sponsor's Full Name
 Sponsor's Title
 Sponsor's Phone Number
Sponsor's Address
 City
 State
 Postal Code

 

Previous Employment
Please list your work experience, starting with your present position. If all or most of your experience has been with the same company, please list any promotions (at least one entry is required).
Company* Title* Years Employed*

 

Education Information
Please List formal education you have completed (at least one entry is required).
Degree* Field of Study* Institution* Completion Date
(mm/dd/yyyy)*

 

Statement of Interest*
Please describe why you would like to participate in the LAMP program and what you expect to obtain from it.

 

How did you hear about the Leadership and Management Program (LAMP)? (Check all that apply)
PSU extension catalog
From my company
Email 		Friend or colleague
Newsletter
PSU Website
Other

Upon acceptance of your application, your submission will be considered an intent to pay. The program fee will be billed soon after the program begins.