Executive Community Orientation Program

ENGAGE South Bend/Mishawaka Application

Applications for the fall 2009 session are due no later than October 1, 2009.

Download and print a PDF of this application Personal Data
Name
Title
Employer

Employer Address
City		State
Zip Code		Work Phone
Work Fax		Work E-mail

Home Address
City		State
Zip Code		Home Phone
Home E-mail

Number of years/months in the Michiana community
Previous community
Spouse name (if applicable)
Will spouse participate in program?
Number of children		Age(s)

Education & Specialized Training
University		Degree(s)
University		Degree(s)
University		Degree(s)

Past Community Involvement (please list volunteer, civic and community activities)
Organization		Position(s)
Organization		Position(s)
Organization		Position(s)

Special Areas of Interest (please list)

	The Chamber of Commerce of St. Joseph County 401 E. Colfax Ave., Suite 310 South Bend, IN 46617 574.234.0051 FAX 574.289.0358 info@sjchamber.org
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