Operations Academy Nomination Form 2020 |

Due Date: May 15, 2020

Name*

First Last

Name to be Printed on Name Tag*

Organization*

Title*

Work Address*

Street Address City State ZIP Code

Work Phone*

Cell Phone*

Email*

Type of Organization*

Federal
State
Local (City, County)
MPO
Private Sector
Other (please specify)

Other Type of Organization

Supervisor Information:

Supervisor Name*

Supervisor Phone*

Mailing Address*

Street Address City State ZIP Code

Supervisor Email*

General Information

Responsibilities*

Other Responsibilities

Briefly describe your current responsibilities*

(Your description may be as long as necessary.

Why do you want to participate in this program?*

(Your description may be as long as necessary.

What do you expect to get out of the program?*

(Your description may be as long as necessary.

Emergency Contact Information

Contact Name*

Phone Number*

Relationship to You*

Nominating Organization Information

(Must be a Federal, state or local transportation agency)

Organization*

Contact Name*

Contact Phone*

Contact Email*

Program Dates and Fees

Please note the dates, fees and select polo shirt size.

Program Dates:
October 19-30, 2020
These dates include the weekend.
Program will begin at 5:00 PM on Monday, Oct 19, 2020

Fees:
Program Fees (required): $3,909
Food & Lodging (required): $2,106
Total Fees: $6,015

You will receive an Operations Academy polo shirt. Please tell us your size:*

Small
Medium
Large
X-Large
2X-Large
3X-Large

Payment Options

How would you like to pay for the program?*

I-95 Corridor Coalition Scholarship*
Purchase Order
Check (made payable to the University of Maryland)
Credit Card (will need to call with number)

*I-95 Corridor Coalition Scholarship Selection Criteria: (click here)

Application Quality
Potential to enhance TSM&O implementation
Active involvement in Coalition activities
Contribution to creating a multi-disciplinary academy
Equitable distribution across Coalition members

All program fees will be due seven weeks after notification of acceptance into the program (August 3, 2020). Any cancellation must be received 60 days prior to the start of the program (August 20, 2020) to receive a refund of all fees, less a non-refundable amount of $500. No refund of any fees will be granted if cancellation occurs with less than 60 days prior to the start of the program.

If you are paying by check, mail your check to:

Lisa Baldwin
Center for Advanced Transportation Technology
5000 College Ave, Suite 2206
Technology Ventures Building
University of Maryland
College Park, MD 20742-6602

October 2020 Operations Academy Nomination Form Due May 15, 2020

Operations Academy Nomination Form 2020

Supervisor Information:

General Information

Emergency Contact Information

Nominating Organization Information

Program Dates and Fees

Payment Options

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