ULCHATT

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Inclusion By Design Execurtive Leadership Program (IBD) is a multi-faceted executive leadership development program. The IBD Program strives specifically to create a pipeline of competitive, highly skilled leaders - BIPOC and women - who are prepared to function successfully in an exectuive assignment.

The IBD Program is structured around 6 exectuive leadership sessions over an 8-month period.

Premier Sponsor: BlueCross BlueShield of Tennessee

First Name

Last Name

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Address

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Gender

Race

Sponsoring Company/Organization:

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Company/Organization Address:

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Company/Organization number of employees:

Name of Chief Executive Officer:

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Name of Immediate Supervisor:

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Name of Nominating Executive:

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Position Title

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Please list your major position responsibilities:

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Number of years in current position:

Number of years in a leadership position:

Number of Employees on the team you lead:

List 3 of your most significant professional accomplishments:

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List 3 of your most significant professional challenges in a leadership role:

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Please list any other leadership development programs in which you have participated:

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List your affiliations and information - e.g., nonprofit boards, professional organizations, volunteer activities - not depicted in your resume:

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Share your career/professional aspirations over the next 5 years

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In 100 words or less, please share how you expect participation in the IBD Executive Leadership Program to benefit your career/professional advancement.

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The Inclusion by Design Executive Leadership Program is structured around 6 exectuive leadership sessions, over an eight-month period. If accepted, I agree to fully participate and will attend 90% of the sessions and 100% of the coaching sessions.

Please submit your resume and any questions you have to BettyeLynn Smith: [email protected] and copy [email protected]