Leadership Gwinnett Application Form

A. BASIC INFORMATION

Full Name:
Preferred Name:
Home Address:
City, State, Zip:
Business Phone:
Home Phone:
Company Name:
Company Address:
Company City, State, Zip:
Email Address:
Date of Birth:
Gender:
Race:
Do you live in Gwinnett?
Total years lived in Gwinnett:
Do you work in Gwinnett?
Total years worked in Gwinnett

The Leadership Gwinnett Program requires 100% attendance and commitment to all activities, events and assignments.
Reception: August 14, 2007 5:00-7:00 P.M.
Fall Retreat: September 14-16, 2007 (Two & a Half Days)
Program Days: October 10, 2007; November 14, 2007; December 12, 2007; January 9, 2008; February 13, 2008; March 12, 2008; April 16, 2008; (Program Days: 7:30 am-@ 5:30pm)
Monthly two-hour study group sessions and homework assignments prior to program days that require time during the week are also included in the program.
Can you commit to 100% participation in retreats, monthly programs, study group meetings and assignments and do you agree that non-attendance/participation is cause of removal from the program?

Please read application in its entirety before beginning to complete remainder. Weight will be given to the effort you put forth in the completion of this application. If you cannot commit 100% at this time, we encourage you to reapply another year when your schedule is more conducive to the program requirements.
B. TUITION AND FUNDING

If accepted into the Leadership Gwinnett Program, you or your company, are totally responsible for the tuition fee of $2,600.00 which covers planned group activities and meals. Full payment will be due by July 20, 2007 if selected for the 2007-08 class.
**A limited number of partial scholarships are available. If selected to participate, would you be seeking scholarship assistance?
If you checked YES, then please provide a detailed explanation of your financial need.

I. COMMUNITY AND CIVIC INVOLVEMENT (Do not include business & professional activities)
Please list in order of importance to you up to five other community, civic, political, religious, social, athletic or other organizations in which you have been active:
Organization - Position - Period of service
Major significant community role as a volunteer:Organization:
Assignment/Position:
Describe responsibilities/accomplishments:
What have you accomplished as a leader in any one or more of these activities that you think is important?
If you have not previously been actively involved in community activities, what conditions have changed that now enable / encourage you to seek such involvement?

II. EDUCATION AND OTHER ACHIEVEMENTS

Please list all colleges and universities attended. Prefix (F) where full-time, (P) where part-time.
School - Location - Dates - Degree/Year
Please list any major distinctions, honors or awards received (academic, military, extracurricular, community, professional) and note the basis for selections:
Please list other leadership or developmental programs in which you have participated:

III. EMPLOYMENT EXPERIENCE
A. Beginning with your current position, please summarize for us your principal employment experience and contributions:Dates:
Name of Organization:
Size/Nature:
Your Title:
Job Description:
Please list your principal accomplishments during this period:

Dates:
Name of Organization:
Size/Nature:
Your Title:
Job Description:
Please list your principal accomplishments during this period:

Dates:
Name of Organization:
Size/Nature:
Your Title:
Job Description:
Please list your principal accomplishments during this period:

List and explain any previous employment of significance to you.

B. What are your career goals?


IV. COMMITMENT:
Why are you interested in becoming a member of Leadership Gwinnett?
Why do you think you would be a good candidate?
What are some of your goals?


V. GENERAL
In your judgment, what are the three most pressing problems facing Gwinnett today? List, explain why and offer recommendations for approaching and resolving these problems.
I hereby certify that the information contained herein is true and correct to the best of my knowledge and grant Leadership Gwinnett's designated representative the authorization to verify any information contained in this application. Enter Name
Dated: