Required fields are indicated by an *.
* NAME OF PERSON COMPLETING APPLICATION:
I. GENERAL INFORMATION
* First Name of Applicant or Nominee:
* Last Name of Applicant or Nominee:
* Title or position
* Institution
* Address
* City:
* State: Select a State Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
* Zip:
* Country Select a Country AbuDhabi Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Bassas de India Belarus Belgium Belize Benin Bermuda Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Caymen Islands Central African Republic Chad Chile China Colombia Comoros Congo Congo, Democratic Republic of Cook Island CostaRica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Denmark Djibouti Dominica DominicanRepublic Ecuador Egypt ElSalvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Fiji Finland France French Guiana Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Holland Honduras HongKong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italia Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Kosova Kuwait Kyrgyzstan Lao People's Democratic Replublic (Laos) Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia NewZealand Nicaragua Niger Nigeria Niue Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal PuertoRico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe SaudiArabia Scotland Senegal Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia SouthAfrica Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania, United Republic of Thailand The former Yugoslav Republic of Macedonia Tibet Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands Wales West Bank Western Sahara WestIndies Yemen Yugoslavia Zaire Zambia Zimbabwe N/A Other Unknown
* Telephone:
* E-mail Address:
* GENDER: I identify my gender as:
* ETHNIC ORIGIN (select one) : Hispanic/Latino(a)(x) Black or African American Native American or American Indian Asian/Pacific Islander White/Caucasian Other (please specify)
* INSTITUTION TYPE (select one) Hispanic-Serving Institution (HSI) Emerging Hispanic-Serving Institution Other
DEFINITIONS
*Hispanic-Serving Institution (HSI) – a nonprofit, accredited college, university, or system/district in the U.S. or Puerto Rico, where total Hispanic enrollment constitutes a minimum of 25% of the total enrollment at the undergraduate or graduate level.
*Emerging HSI – a nonprofit, accredited college, university, or system/district in the U.S. or Puerto Rico, where total Hispanic enrollment constitutes at least 10% of the total enrollment, or where a minimum of 1,000 Hispanic students are enrolled at the undergraduate or graduate level
II. EDUCATION
* Highest degree obtained BA/BS/BBA MA/MS MBA Ed.D JD/Law Ph.D. MD Other (please specify)
* University conferring degree
* Field of study
* Graduation Year
III. WORK EXPERIENCE
List your or the nominee’s positions in reverse chronological order, starting with the current or most recent one. If all positions are in the same higher education institution, please give the major promotional sequence.
* 1. NAME OF INSTITUTION
* TITLE OR POSITION
* FROM / / (MM/DD/YYYY)
* TO / / (MM/DD/YYYY)
* 2. NAME OF INSTITUTION
* TITLE OR POSITION
* FROM / / (MM/DD/YYYY)
* TO / / (MM/DD/YYYY)
* 3. NAME OF INSTITUTION
* TITLE OR POSITION
* FROM / / (MM/DD/YYYY)
* TO / / (MM/DD/YYYY)
* 4. NAME OF INSTITUTION
* TITLE OR POSITION
* FROM / / (MM/DD/YYYY)
* TO
/ / (MM/DD/YYYY)
5. PLEASE ESTIMATE TOTAL YEARS OF PROFESSIONAL EXPERIENCE:
* Number of Years:
6. PLEASE UPLOAD A COPY OF YOUR (OR THE NOMINEE'S) CURRICULUM VITAE.
* Upload CV Here:
(Please make sure the name of the uploaded file does not contain any characters like periods, hyphens or slashes.)
7. Describe your (or the Nominee’s) current responsibilities, including level in the organization.
* (500 word limit)
8. Explain the objectives and goals as they relate to you (or the Nominee) attending this program. Also describe what you think other program participants may learn from your (or the Nominee’s) participation in this academy (e.g., perspectives, skills, expertise).
* (500 word limit)
9. What do you anticipate are the next steps in your (or the Nominee’s) career progression to a presidential position?
* (500 word limit)
10. How would you characterize your (or the Nominee’s) leadership strengths and weaknesses? Provide examples as appropriate.
* (500 word limit)
11. What are the most formidable challenges facing college presidents today?
* (500 word limit)
12. Applicants who are unable to secure funding from their institution to participate in the program are eligible for consideration for a fellowship. Ten applicants will be selected. Please indicate how this fellowship will support you in your career. What makes you an ideal candidate for this support?
* (500 word limit)
IV. LETTERS OF REFERENCE INFORMATION
HACU’s La Academia de Liderazgo requires that two letters of reference be completed by a senior executive or board member within the institution, or a colleague or former supervisor familiar with the candidate’s character, role, and responsibilities, who can provide a detailed firsthand account of the applicant’s leadership potential, skills and abilities.
FIRST REFERENCE:
* Referring Institution Name:
* Name of Reference:
* Title or Position:
* Email:
* Referring Institution Name:
* Name of Reference:
* Title or Position:
* Email:
* Upload Reference Letter 1
(Please make sure the name of the uploaded file does not contain any characters like periods, hyphens or slashes.)
* Upload Reference Letter 2
(Please make sure the name of the uploaded file does not contain any characters like periods, hyphens or slashes.)
V. BILLING INFORMATION
Tuition is $10,000 for HACU-Member institutions and $15,000 for non-members per selected participant. Tuition covers all program materials, HACU conference registrations and selected meals. An invoice will be emailed to the individual indicated below.
* NAME:
* TITLE OR POSITION:
* INSTITUTION NAME:
* INSTITUTION ADDRESS:
* CITY:
* STATE: Select a State Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
* ZIP CODE:
* INSTITUTION TELEPHONE:
* FAX:
* EMAIL:
VI. CANCELLATION POLICY Payment is due within 30 days of the invoice date. Cancellations or deferrals must be submitted in writing more than 30 days before the program start date to receive a full refund. Due to program demand and the volume of preprogram preparation, cancellations or deferrals received 14 to 30 days before the program start date are subject to a fee of one-half of the program fee. Requests received within 14 days of the program start date are subject to full payment of the program fee.Upon acceptance, payment is required prior to the program start date.
* I have read the cancellation policy and agree to the terms stated. (initial here):