Local Government Supervision Certificate Program
Nomination Form

Please accept this nomination to the MARC's Local Government Supervision Certificate Program.

Supervisor's Name: __________________________________________________________________________

Title: __________________________________________  Department:  ________________________________

Agency: ____________________________________________________________________________________

Address: ___________________________________________________________________________________

City: __________________________________________  State:____________________  Zip: ______________

Work Phone: _______________  Fax:_______________  Email: ______________________________________

Authorizing Manager's Name: ___________________________________________________________________

Authorizing Signature: _________________________________________________________________________

I authorize MARC to bill our agency for the $500 cost of the initial assessment and the completion of an individual development packet.

Return form to Government Training Institute, Mid-America Regional Council, 600 Broadway, Suite 200, Kansas City, MO 64105-1659 or fax to 816/421-7758.