Columbus State UniversityExecutive CollegeA Program of Columbus State University

Continuing and Justice Administration Outreach

4225 University Avenue - Columbus GA 31907Phone (706) 568-2190 Fax (706) 568-2137

Dr. Archie Rainey Ms. Laurie SkibbeDirector Associate Directorarainey@columbusstate.edu www.ColumbusState.edu/command skibbe_laurie@columbusstate.edu

Appointment Application

__________________________________________________________________________________________________Last Name First Name Middle Name SS Number

__________________________________________________________________________________________________Title/Position

__________________________________________________________________________________________________Organization/Agency

__________________________________________________________________________________________________Street Address City State Zip Code

__________________________________________________________________________________________________Phone Number Fax Number

__________________________________________________________________________________________________E-Mail

Years of service with current employer ________________________

Years in supervisory positions ________________________________

Education Level:

______60 Semester Hours\90 Quarter Hours

______Bachelors Degree ______Graduate Degree

Training:

______________________________________________________________________________________________

______________________________________________________________________________________________In addition to the Appointment Application, you are required to submit a resume a completed nomination form.

__________________________________________________________________________________________________Signature of Applicant Date

NOMINATIONTO ATTEND THE COLUMBUS STATE UNIVERSITY EXECUTIVE COLLEGE

The Executive College is an advanced program of study focusing on developing leadership and management skills.The program will require at least 280 hours of classroom study divided into seven (7) modules extending over aperiod of approximately two (2) years with significant out-of-class assignments. To include an independent researchproject.

Nominee:

__________________________________________________________________________________________________Last Name First Name Middle Name SS number

__________________________________________________________________________________________________Title/Position Organization/Agency

__________________________________________________________________________________________________Agency Address Phone Number

Nominated By:

__________________________________________________________________________________________________Last Name First Name Middle Name

__________________________________________________________________________________________________Title Position Organization/Agency

I hereby nominate ______________________________________________________________________________________Name of Nominee

of the __________________________________________________________________________________________________Name of Organization or Agency

to attend the Columbus State University Executive College.

__________________________________________________________________________________________________Signature of Nominator Date

MAIL TO: Archie Rainey, Ph.D.Justice Administration OutreachColumbus State University4225 University AvenueColumbus, GA 31907-5645Phone: (706) 568-2190Fax: (706) 568-2137E-Mail: arainey@columbusstate.eduWeb Site: www.ColumbusState.edu/command