Leadership Academy Form | Maryland Association of CPAs (MACPA)

Section 1: Personal Information

First Name*

Last Name*

Suffix

Home Phone*

Email*

Member ID

Date of Birth*

Home address 1

Home address 2

City

State

Zip / Post Code

Work Phone

Firm/Company Name

Work address 1

Work address 2

City

State

Zip / Post Code

Licensed CPA?

Yes
No

Professional focus (check all that apply)

Public Accounting
Business and Industry
Government
Non-profit
Education
Other

Firm Size:

<10
10 – 49
50-200
>200

Section 2: Education

Please specify the highest level attained:

BA Degree
MA Degree
PhD Degree
Other

List leadership positions held, special honors and awards received:

Section 3: Work Information

Present job title or position:

Direct supervisor’s name:

What do you consider your highest career achievement to date?:

Employment Record (list most recent first and include employer name, position held, and period of service):

Business / Professional Affiliation (list most recent first and include name of group, position held, and period of service):

Section 4: Community Involvement

Include community, civic, religious, political, social, athletic or other activities. Please include organization name and description of involvement:

Section 5: General

What do you hope to gain from the Leadership Academy?:

What do you think are the most important issues facing the accounting profession and why?:

Who is sponsoring you for Leadership Academy?:*

Discount Code?

Section 6: Committment

I understand the objectives of the BLI Leadership Academy program and recognize the value of participating. If I am selected, I will devote the time and resources necessary to complete the program to the best of my abilities.

Full Name to be used as Signature:*

Date:*

Questions? Email info@BLIonline.org or call 888-481-3500