ENCOUNTER Charlotte Application

Please note the following instructions to successfully complete the application process. Applications are accepted on a first come-first paid basis.

Please type your answers using the space provided. Please do not send additional pages, bios or resumes.
Complete the application in one sitting. This application does not include an option to save and exit the application, then go back and finish it later.
You must click ‘SUBMIT’ at the end of the application in order for it to be received.
Please contact our office with any additional questions, 704-688-2888.
The $350 fee may be paid by credit card using the online payment option or mailing a check made out to “Leadership Charlotte.”
Click Here to pay online or please mail check to: Leadership Charlotte, PO Box 11757 Charlotte, NC 28220-1757; reference ENCOUNTER Charlotte

Prior to April 25, 2012 payments are refundable less a $25 processing fee. No refunds after April 25, 2012.

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PERSONAL DATA
Date of Birth*
Gender*
Race/Ethnicity*
Name*
FirstLast
Preferred to be called*
Employer*
Occupation/Title: *
Preferred Mailing Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code
Please designate what type of address this is:*
- Home
- Business
Preferred Phone*
Please designate what type of phone number this is:*
- Home
- Business
- Cell
Preferred Email*
Please designate what type of email this is:*
- Home
- Business
Emergency Medical Contact Name:*
FirstLast
Relationship to you: *
Phone*