EmailMeForm
Name
*
First
Last
Utility Name
Address
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
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Cuba
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Mexico
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Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
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Ecuador
Guyana
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Peru
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Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
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Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
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Afghanistan
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Brunei Darussalam
Myanmar
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China
East Timor
Hong Kong
India
Indonesia
Iran
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Israel
Japan
Jordan
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North Korea
South Korea
Kuwait
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Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Email
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Confirm
Phone
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Fax
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Cell
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How many years have you attended CS Week?
Utility Type
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Electric
Gas
Water/Wastewater
Other
Utility Size
*
<100,000
100,000-250,000
250,000-1,000,000
>1,000,000
What are your current utility roles and responsibilities (include whether predominately customer service or information technology)?
*
Why are you interested in participating with LeadNext?
*
What makes you a good nominee for LeadNext?
*
Nominee Signature & Title
*
Executive Sponsor Name & Title
*
With my signature below, I acknowledge and agree to the LeadNext program requirements and to support the nominee in the following ways (program fees and travel funding for 2 CS Week Conferences; travel funding for 2 offsite one-day meetings; and allowable work time spent attending CS Week Conferences and venues, webinars, offsite meetings, monthly calls and performing LeadNext assignments).
The fee for the LeadNext program is $5,500. This fee covers participation in the leadership program, 2 CS Week Conference registrations, Deep Dive or EVCx Forum session and 1 Executive Summit registration and all webinars. This fee does not include travel funding. (Terms are Net 30 and an invoice will be sent upon notification of acceptance of nominee as participant).
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I agree to the requirements
Email
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Phone
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Date Time
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