State and Local Government Benefits Association

SALGBA Leadership Certification Application

SALGBA offers participants in the SALGBA Leadership Series to receive a Leadership Certificate based on the following criteria:

Participants employer is a SALGBA Member in good standing
Participant attended 4 hours out of 6 hours of leadership series sessions as confirmed on session attendee list
Payment of the $25 application fee upon acceptance of the form (to be invoiced after form is submitted and approved)

If the above criteria has been met/accepted, please complete the form below.

Full Name of Applicant (to be used for certificate):

Certificate Year requested (based on calendar year such as 2016):

Applicant's Mailing Address:

City, State, Zip Code:

Applicant's Email Address:

Applicant's Phone Number:

Applicant's Employing Organization:

I certify that I have participated in at least 4 leadership series hours within the calendar year requested.:
Acknowledged

I certify that my employing organization is a member of SALGBA in good standing.:
Acknowledged

I understand that my application will be reviewed and if accepted there is a $25 fee to be paid before my certificate will be issued.:
Acknowledged

Please Enter The Letters and/or The Numbers You See In The Above Box:

SALGBA commends your drive for professional development. Leadership skills are a tool that can be used across many facets of one's life.

SALGBA also offers a Certified Government Benefits Administrator Program and encourages you to obtain a CGBA designation if you have not already done so. More details on CGBA and the Leadership Certificate can be found at http://www.salgba.org/professional_development_info.php.