2016: Class 11 Program Application

*Please provide this information as you would want it printed in publications; For the
Business Address, please include all relevant mail locations, internal P.O. boxes,
etc. This WILL be used for mailing purposes.
DATE:
CONTACT INFORMATION
NAME:
(Last)

(First)

(Middle)

POSITION:
HOW LONG IN THIS POSITION:
COMPANY/ORGANIZATION:
BUSINESS ADDRESS (will be used for mailing purposes):
(# Street/Suite)
BUSINESS ADDRESS (cont):
(City/State)

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(Zip)

BUSINESS PHONE
BUSINESS E-MAIL:
IMMEDIATE SUPERVISOR:
SUPERVISOR BUSINESS PHONE:
SUPERVISOR E-MAIL:

HOME ADDRESS:
(Street #)

(City/State)

(Zip)
HOME PHONE:
NEIGHBORHOOD:
YEARS LIVED/WORKED IN REGION:
REFERRED BY/HOW HEARD (please indicate by whom you were referred or how you heard
about the C-Change program):
OPTIONAL: To achieve an inclusive program, please provide the following information:
BIRTHDATE:
RACE:
GENDER:
COUNTRY OF ORIGIN:
PREFERRED T-SHIRT SIZE:
S
M
L
XL
XXL
XXXL
Have you previously applied to any Cincinnati USA Regional Chamber Leadership
program(s)? If so, which program did you apply for and when (Leadership Cincinnati,
Leadership Action, Cincy Next, C-Change, WE Lead or WE Succeed)?
TYPE
HERE:
ORGANIZATION CLASSIFICATION: (please check one)
Accounting
Arts
Business, Lg. (>250 emp.)
Business, Sm. (<250
emp.)
Clergy
Communications/Media/PR

Education
Entrepreneur
Finance/Banking
Government

Marketing/Advertising
Medicine/Healthcare
Scientific/Technical
Social Services

Labor
Law

Community Volunteer
Other (Please Specify)

Describe the nature & size of your organization in 50 words or less:

TYPE
HERE:
EMPLOYMENT
(Begin with your present employer and go back successively through your last three
employers.)
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From To

Name & Location of Employer

Position

Reason for Leaving

EDUCATION
(List college degree(s) and/or any other specialized training):
Name & Location of School

From To

Degree

Major

Extracurricular Activities, Awards and Responsibilities (please indicate school):

TYPE
HERE:
Leadership Positions Held (please indicate school):
TYPE
HERE:

COMMUNITY ORGANIZATIONS & ACTIVITIES

(Please list membership in community, civic, business, professional, religious and social
organizations that have been of significance to you.)
Organization

From To

Responsibilities or Position Held

Attach a separate page if necessary.

CREATIVE SOLUTIONS
1. Provide an answer to the following question. (Please keep your response to 150 words.)
The Cincinnati region, like most across the country, is consistently working to attract
additional talent to our community. Share 1-2 of our key community assets (i.e. the river,
quality of life, etc) that, in your opinion, should be leveraged as a significant part of a
campaign for talent.
TYPE
HERE:

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2. Discuss up to 3 of your greatest accomplishments: Briefly describe the situation, actions

taken, the results and your leadership role.
TYPE
HERE:
3. Describe a time, either professional or personal, when you failed or really messed up.
Include how you handled it, who you involved, the outcome, and what you learned from the
experience.
TYPE
HERE:
MORE ABOUT YOU:
4. What are some goals (maximum of 3) youd like to achieve through participating in CChange, both during the program year, as well as beyond? (Please include community as
well as professional, and keep your response to 150 words.)
TYPE
HERE:
5. C-Change has become very competitive. Why should you be selected for C-Change?
(Please keep your response to 150 words.)
TYPE
HERE:
6. What else can you tell us that will help us get to know you better as an individual? (This
could be personal or professional, serious or fun. (Please limit your response to 150 words)
TYPE
HERE:

REFERENCES
For your primary reference, please list the person who is most knowledgeable about your
leadership performance and potential, and have her/him complete the separate reference
form.
No other recommendations are required. No more than two reference forms should be
submitted.
Primary Reference (Completed Form Required)
NAME:
PHONE:
ADDRESS:
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(# Street)

(City/State)

(Zip)

E-MAIL:
Other References (completed form or statements not required)
NAME:
PHONE:
ADDRESS:
(# Street)

(City/State)

(Zip)

(# Street)

(City/State)

(Zip)

E-MAIL:
NAME:
PHONE:
ADDRESS:
E-MAIL:

Do not attach a resume or any other document to this form.

2016 ATTENDANCE REQUIREMENTS

Class sessions meet the third Wednesday of each month from 8:30 a.m. 4:30 p.m.
(excluding August, and with the exception of July 2016). Participants are expected to attend
all sessions. Those who miss more than two sessions will be denied graduation and asked to
withdraw from the program.
Wednesday Jan. 20: Opening Reception
June 15
Friday-Saturday Jan. 29-30: Overnight Retreat
July 27
Feb. 17
Sept. 21
March 16
Oct. 19
April 20
Nov. 16
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May 18
Commencement

Dec. 14 (tentative):

Participants will also work in smaller teams on a community project throughout the year.
Each participant is expected to be actively and fully engaged with his or her project, which
may include time outside of scheduled sessions. Those who are not participative in the
project risk successful completion of
C-Change.
Will you be able to fulfill this commitment?

Yes

No

Do you have full support of your employer for the required time to participate in the
program?
Yes

No

NA

I understand the purposes of C-Change, have reviewed the attendance requirements and
agree to devote the time and energy necessary to make it a successful experience if I am
selected to be a participant.
CANDIDATES SIGNATURE:
DATE:
TUITION
Tuition for employees of Chamber member organizations is $3,300. If your employer is not a
Chamber member or if you are unsure, contact Julie Bernzott at 513-579-3113 or
jbernzott@cincinnatichamber.com
Tuition is nonrefundable and due in full by January 8, 2016 unless arrangements have been
made to pay in installments.
Tuition will be paid as follows: (If combination, indicate amounts)
Personally

Sponsoring organization/company

Partial grants of up to $1300 may be available for small non-profits or entrepreneurs based
on need.
Do you plan to apply for grant money?
No

Yes

Amount requested $

Please download, complete & submit the grant request form if you would like to be
considered.

APPLICATION PROCESS CHECKLIST

PLEASE RETURN: 1) Completed Application (no staples please)
2) Completed Reference form
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3) $50 application fee (nonrefundable) payable to: Cincinnati USA

Regional Chamber
4) Digital photo (color, 300 dpi in JPEG format, business attire)-please email
to
jbernzott@cincinnatichamber.com
5) Optional-Completed Grant Request Form
*If possible, please return all of the above items together in one package/e-mail.
APPLICATION FEE
A nonrefundable application fee of $50.00 is due with your completed application. You may
pay via one of the following methods:

By check: Please make check payable to: Cincinnati USA Regional Chamber and
return to:
Julie Bernzott
Cincinnati USA Regional Chamber
3 East Fourth Street
Suite 200
Cincinnati, OH 45202

By credit card by calling the Chambers Customer Focus Center at 513-579-3111 or

by providing credit card information below:

____Visa
Express

____MasterCard

____Discover ____American

Credit Card Number: ___________________________________

Expiration Date: ____/_________
Name on Card: _______________________________________

SUBMIT VIA E-MAIL, MAIL OR DELIVER TO:

Julie Bernzott
C-Change
Cincinnati USA Regional Chamber
3 East Fourth Street, Suite 200
Cincinnati, OH 45202
jbernzott@cincinnatichamber.com

APPLICATION DEADLINE: Sept. 21, 2015. (Must be postmarked by this date for
consideration)

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