APPLICATIONS CLOSED! 
Sign in to Google to save your progress. Learn more
Email *
Are you applying for the CPTM or CGCIO program? *
Please make sure you have reviewed the criteria for both programs on the website and choose the one that is most appropriate.
Required
About You
This section collects information about you.
First Name *
The name that you would like on your certification recognition, plaque, etc., e.g. "William" rather than "Bill".
Nickname
Name you prefer to be called, e.g., "Bill" instead of "William".
Middle Initial
If desired for certification recognition, plaque, etc.
Last Name *
Title *
Department/Unit
Organization *
Mailing Address *
E-mail Address *
Office Phone *
Cell Phone *
For use in emergency situations. Program communcation will be primarily via e-mail and the online course system.
Social Media Profiles
Feel free to share your LinkedIn, Twitter, or other social media information. 
About Your Organization
In this section you will provide information related to your work.
Name and Title of Immediate Supervisor *
Mailing Address of Immediate Supervisor *
If you have the same mailing address, write "Same".
Telephone of Immediate Supervisor *
E-mail Address of Immediate Supervisor *
Name and Title of Organization Leader/CEO *
If the organization leader is the same as your immediate supervisor, write "Same".
How long, in years, have you worked in the technology field? *
How long, in years, have you worked for your current employer? *
How long, in years, have you held your current position? *
Please provide a brief description of your current duties and responsibilities. *
How many individuals do you supervise? *
If no employees are supervised, write "0".
Your Background
In this section, you will tell us a little about you and your goals.
Please provide a brief description of your leadership experience/training to date. *
Please list your highest degree attained and any current certifications you hold. *
What conferences/networking events have you attended in the past year? *
What have you read in the past 6 months? *
Include books, articles, magazines, anything at all that you have read.
The Program
In this section, we want to know a little more about how the program can help you and how you can contribute to the program.
Why do you think you were selected for the position you currently hold? *
List at least one leadership goal you want to accomplish in the next 5 years. *
What do you hope to gain from this program? *
What unique qualities, skills or experiences can you contribute to the program? *
Writing Sample: Please submit a writing sample as part of the application process. Click here to download the writing sample instructions. Note receipt of the instructions in the response box. *
Your Commitment
By submitting this application, you agree to the following terms: I accept the responsibility of participating in this program and understand that:

• I must attend all hours of scheduled classes and complete assigned work on time and in a quality manner to receive certification;  

• My voice in this program is valued and important to my success in the program as well as to the effectiveness of the program. I commit to being actively engaged in the in-person sessions and in the online classroom;

• I will prepare in advance for each class session and will leave my cell phone, laptop or other device off during class hours;

• Violation of any of the above program principles can result in my removal from the program.  

• I will be required to complete continuing education hours to maintain my certification.

Sign Here *
By typing your full name, you are signing this document and affirming that you understand and agree to the requirements of the program.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms