Leadership Program Application - Marion County Adult Leadership

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Leadership Program Application

Name:
Telephone:
Address:
City: State: Zip:
Employment:
Business Firm:
Your Title:
Length of service with present organization:
Brief Job Description:
Organizations and Activites:
List memberships in community, civic, professional, business, religious, social, or other organizations during the past five years. (list in order of importance to you):
How many hours per month are you currently committed to community, civic, professional and other organizations and activities?
Are you a registered voter in your community? Yes No
What do you hope to gain from your involvement in Leadership?
In your opinion, what are the three most important issues facing your community today? Give any recommendations for resolving these issues.
A.
B.
C.
In order to better get to know you, what other information would you like the selection committee to know about you?
Please name two persons in your community whom the selection committee could contact for additional information:
1.
Name:
Telephone:
Business Address:
City: State: Zip:
2.
Name:
Telephone:
Business Address:
City: State: Zip:

The information submitted in this application is true and correct to the best of my knowledge. Email Address:

South Shore • 301 East Main Street • P.O. Box 209 • Flippin, AR 72634 • © , All rights reserved • www.southshore.com
(870) 453-8800 • (800) 775-6682 • South Shore was founded by and is fully supported by NATCO (Northern Arkansas Telephone Company).