DLA Application

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Name

Preferred Email

Preferred Phone

Street Address

City

State

Zip

I certify that I can meet all requirements of the program and that I am recommended by my Club President for admission to the DLA.

If accepted, I understand that to be admitted I must pay the non-refundable tuition prior to the start of the program. Please send a check for $150 to Rotary District 6110, 8209 E 63rd Place, Tulsa, OK 74133. Include “District Leadership Academy” in the check’s note field. Contact District Administrator, Cole Adamson, for information on credit card or other payment methods (districtadministrator@district6110.org).

Rotary Club Name

Rotary Positions Held