| 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?
|
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:
|
|
|
