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LOUISIANA MUNICIPAL<br />
MUNICIPAL<br />
ACADEMY<br />
LEADERSHIP 6767 Perkins Road, La 70808<br />
Telephone: 225-344-5001<br />
LEADERSHIP ACADEMY CREDIT APPLICATION FORM<br />
Date<br />
_______/ ____/ ________<br />
Please fill out the form below. Applications can be mailed to the Academy address above with Attn: LMLA program on the envelope.<br />
Important Deadline: To be recognized in the current conference year, submissions must be made by JULY 1. Any submissions made<br />
after JULY 1 , will be recognized at the next year’s conference.<br />
Name: ___________________________ Title: __________________ Municipality:____________________<br />
Address:__________________________<br />
_______________________________<br />
Email________________________________________________<br />
Phone:_______________________________________________<br />
Please list all conferences and meetings attended. Please include the Title, Date and Points Earned. For webinars, include the<br />
title and month.<br />
Title of Program Date Points<br />
Earned<br />
_________________________________________________________________________________________________________________<br />
_____________________________________<br />
__________________<br />
__________________________________________________________________________________________________________________ ______________________________________ __________________<br />
__________________________________________________________________________________________________________________<br />
_____________________________________<br />
__________________<br />
_________________________________________________________________________________________________________________<br />
_____________________________________<br />
__________________<br />
__________________________________________________________________________________________________________________<br />
____________________________________<br />
__________________<br />
__________________________________________________________________________________________________________________<br />
____________________________________<br />
__________________<br />
__________________________________________________________________________________________________________________<br />
____________________________________<br />
__________________<br />
I hereby certify that the above attendance and credit record are accurate to the best of my knowledge, and further understand<br />
that if I willfully submit false attendance records, it may result in my exclusion from LMLA eligibility.<br />
X:__________________________________<br />
Signature<br />
District Meetings.................................................................................................................................<br />
Municipal Day at the Capitol.....................................................................................................<br />
Mid-Winter Conference..................................................................................................................<br />
LMA Annual Convention..................................................................................................................<br />
Webinars....................................................................................................................................................<br />
1/2 point each<br />
1 point<br />
2 points<br />
5 points<br />
1 point<br />
Questions? If you have any questions, please contact Erin Walker, LMLA Director at 225-332-7638 or ewalker@lma.org.<br />
LMR | FEBRUARY 2<strong>02</strong>4 Page 21
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