Data Literacy for Leaders Program Application Program information Program Application Personal Information SalutationPlease select... Mr. Ms. Mrs. Mx. Miss Dr. Prof. The Honorable Brig Gen Captain Commander Chief Master Sergeant Colonel First Lieutenant General Lieutenant Lieutenant Commander Lieutenant Colonel Lieutenant General Major Major General Master Sergeant Rear Admiral Vice Admiral First Full Name Middle Name or Initial(s) Last Name Nickname Job Title OccupationPlease select... Acquisition/Contract Management Business and Operations Communications Finance Human Resources Information Technology Medical/Public Health Science/Engineering Other Are you a:Federal Government EmployeeState or Local Government Employee Department or Agency If your agency is not listed, type and select "Other". Other Department or Agency Please avoid acronyms Subcomponent (please avoid acronyms) StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands Northern Mariana Islands Guam American Samoa Palau City, County, or Municipality Agency Name What level of government do you primarily work for?Please select... State County City Town Tribal Regional/Metropolitan Other (please specify) Other level of government: Office or Work Unit Please avoid acronyms Full Agency Name Preview Above is how your agency name will appear in our records. If this naming convention is incorrect, please check the box below.Override agency naming convention Full Agency Name- Manual Input Contact Information Work Email Personal Email Preferred Email AddressPlease select... Personal Work Preferred Phone NumberPlease select... Work Mobile Home Work Phone Mobile Phone Home Phone Street City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip Code Emergency Contact Name Emergency Contact Phone Supervisor Information SalutationPlease select... Mr. Ms. Mrs. Mx. Miss Dr. Prof. The Honorable Brig Gen Captain Commander Chief Master Sergeant Colonel First Lieutenant General Lieutenant Lieutenant Commander Lieutenant Colonel Lieutenant General Major Major General Master Sergeant Rear Admiral Vice Admiral Supervisor First Name Supervisor Last Name Supervisor Job Title Supervisor Phone Supervisor Email City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip Code Professional Experience and Objectives Total years with current agency Numerals only Total years of government service Numerals only Participation format preference Supplemental Information How did you hear about this program?Please select... Partnership staff member Colleague Agency leadership LinkedIn Other Other Please check the box to acknowledge that by submitting this application you may receive emails from the Partnership for Public Service. You may unsubscribe at any time.I understand that the Partnership may send me emails. Contact Information By submitting this application, you agree to receive emails from the Partnership. You may unsubscribe at any time.
