Public Media Diversity Leaders Initiative Application

Section One: General Contact Information
Name Name First Last
Email
Job Title
Station Name or Affinity Organization
Licensee Type (Select all that apply.)

Licensee Type (Select all that apply.) Television Radio Joint
Areas or Regions Served:
Audience Size

Audience Size Small Medium Large
Applicant's Gender
Applicant's Race

Applicant's Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White I prefer not to answer Other Other
Applicant's Ethnicity

Applicant's Ethnicity Hispanic or Latino Not Hispanic or Latino I prefer not to answer
Work Mailing Address Work Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Shipping address (if different than above)
Work Phone Number Work Phone Number - ### - ### ####
Cell Number Cell Number - ### - ### ####
Assistant's Name Assistant's Name First Last
Assistant's Email Address
Include assistant on class-related emails?

Include assistant on class-related emails? Yes No
Your name as you would like it to appear on graduation certificate:
Section Two: Open-Ended Response
What do you think is the greatest single challenge to advancing diversity, equity, and inclusion within your system?
How did you hear about PMDLI?

How did you hear about PMDLI? Referred by an alum Internet search Other (please specify) Other (please specify)
Who was the alum that referred you?