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Please note: If you are registering on behalf of someone else, you will need to register using their information or contact us at 1-800-663-7305 or Once you click on the register button at the bottom of the form you are registering for this program. If you would like information about final price, accommodation, etc, please email

Application Form

Executive Leadership Program (by admission only)

April 29-May 3, 2019, Niagara-on-the-Lake

First Name: *
Last Name: *
Title: *
Organization: *
Phone: *
E-mail Address: *
Street Address: *
City: *
Province/State: *
Postal/Zip Code: *
Country: *

Alternate Contact Details (secretary or executive assistant):


Additional Information

Organization Details:

Web site:
Parent (if applicable):
Annual Revenue ($):
No. of Employees:

Typical Titles of the top two levels of management in your organization:

Applicant Details:

Direct Boss:


Current Responsibilities:

No. of Direct Reports:

Typical Titles of your Direct Reports:

Describe your current responsibilities:

Functional Area of Responsibility:

Total No. of People in your Functional Area:

Budget Size or Revenue Targets of your Functional Area ($):

List and describe the departments within your current area of responsibility:

Describe your key past or present accomplishments:


No. of years in management:
No. of years in senior management:
No. of years of international experience:
Past Positions: Title Organization Years

Education: Include formal education (university, executive and in-company programs).

Institution #1

Year Completed:

Institution #2

Year Completed:

Please let us know how you found out about The Niagara Institute (select all that apply):

Privacy Policy

Prior to attending this program, you will receive and complete confidential assessment surveys. Please take a moment of your time to review some additional information about Niagara’s policies and practices on the privacy of Personal Information, Research, and Quality Assurance and click on the ‘I have read’ button below.



Please make any additional comments below and inform us of any special request you might have regarding your registration (invoicing instructions, additional accommodation, dietary issues, etc.) prior to sending. Thank you.

All meals and five nights of accommodation are included in the program fee. We will provide you with the full details after your registration is processed.

Promotion Code

If you have a Promotion Code, please enter it here:

Withdrawal and Rescheduling Policy

The Niagara Institute is committed to fully meeting the needs of all participants and the delivery of the highest quality programs. To maximize participant learnings, Niagara strictly controls class size and invests heavily in pre-program preparation, incurring substantial administrative, analytical and opportunity costs. Please view our Withdrawal and Rescheduling Policy.