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Leadership in Life Institute Moderator Application
for 2008 LILI Moderator Training Conference

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Application must be completed and submitted online.
Moderator Agreement and Endorsement Page must be printed and faxed
to NAIFA-LILI Director with all required signatures by deadline.
Deadline for completed applications and endorsements: June 30, 2008

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I. Background Information
* Required Fields
1. Member ID (7 digits)
2. Last Name *	First Name * MI
3. Titles and Designations
4. State Sponsor *
5. Company Affiliations
6. Business Address:
	City State Zip
7. Business Phone:
Fax:
8. Business e-mail:
Cell:
9. In the Business Since:
* Member of NAIFA Since:	* 2-year minimum active membership required
Local Association Name:
10. Primary Industry Activity:	(Select One Only)
	Agent  PPGA Supervisor GA, Manager
	Trainer Brokerage Mgr. Other
11. Licenses/Registrations:	Life  Health  P & C  NASD
12. Company Type:	Ordinary  Home Service Multiline Brokerage
II. Education
1. Highest Education Level Completed:
	High School  Some College College Degree   Major   Postgraduate Degree Major  LILI Graduation State Date Moderators Name
2. Did you miss any class sessions?	No Yes  If so, why?
What was the main thing you personally gained from your first LILI experience?
III. Experience
1. Please describe any experience have you had with class management or facilitation. Include type/name of program and years involved. (example-LUTC, Chamber, Counseling, Teaching, etc.)
2. Have you previously moderated a LILI class?	State Years State Years
3. Do you have public speaking experience? Please describe this experience to include type/name of program and dates
4. Have you ever been an Agency Manager, General Agent, Sales Manager or any other position in the industry where you "led" other people?
IV. Tell Us About You
1. Why do you want to be a LILI Moderator?
2. What do you feel you have to offer as a Moderator of a LILI class?
3. What do you expect to gain by being a LILI Moderator?
V. Industry Activities and Involvment
1. List local associations leadership positions and dates
2. List state and national associations leadership positions and dates
3. List community and civic-based leadership positions and dates
VI. Class Information
Approximate Dates
1. Class Start Date:
2. Commencement Date:
3. Address Where Class Will Be Held:

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