Level 2 Form

This certificate is intended to be completed during or after a second term in office.

Application Information

Name*

Title First Last

Phone Number*

Email Address*

Mailing Address*

Street Address City State / Province Postal Code

Number of Complete Terms Served as an Elected Official*

Name of Local Government*

Requirements to qualify for the Level 2 Advanced Certificate in Local Government Leadership

Completion of Level 1 Certificate in Local Government Leadership

Please indicate the date you were awarded your Level 1 Certificate in Local Government Leadership.*

Date Awarded	Certificate Level

An additional 30 hours of course work

A minimum of 15 hours must be acquired at regular LGLA events (i.e., Annual Leadership Forum, Chief Elected Officials Forum).*

Which ones did you attend?

(For multi-day events, enter 1st day of event as ‘Date Taken’)

Date Taken	Select LGLA Event

The remaining 15 hours may be acquired at other learning events sponsored by an approved agency listed in LGLA’s List of Approved Courses.*

Here is a list of LGLA’s Approved Courses.

Which ones did you attend?

(For multi-day events, enter 1st day of event as ‘Date Taken’)

Date Taken	Hours	Title of Course	Sponsor Organization

Terms and conditions

Please note: The information on this form is collected for the purposes of awarding a certificate to recognize the completion of educational courses provided by the LGLA and will be used to process your application. If you have any questions about the collection and use of the information, contact LGLA staff at info@lgla.ca or 778.800.9952

I declare that the information contained in this application is correct.*

I hereby authorize the LGLA and its agents to communicate with any organization that I have listed as a course sponsor in Appendix 1 for the purposes of verifying my qualifications for this certificate.*

I consent to my name being published in LGLA communications if awarded a certificate.*

Yes
No

Signature*

Level 2 Form

Level 2 – Advanced Certificate in Local Government Leadership Qualifications

Application Information

Requirements to qualify for the Level 2 Advanced Certificate in Local Government Leadership

Terms and conditions