Street City/State Zip s1

Application

Provide the following information for consideration by the Selection Committee. Participants are selected on the basis of current and potential contributions to leadership in Germantown. Applications must be typed or printed clearly in black ink and filled out COMPLETELY. Incomplete applications may be disqualified.

Name: ______Last First Preferred

Home Address: ______Street City/State Zip

Business Address: ______Street City/State Zip

Home Phone: ______Business: ______Cell: ______

Email: ______Fax: ______

Employer / Type of Business: ______Date Began: ______

Present Position: ______Date Began: ______

Briefly describe your responsibilities:

You are required to attend ALL sessions for graduation of this program.

Will you be able to attend all class sessions? Yes No

Is your employer willing to support this commitment? Yes No

* Specific dates will be provided upon acceptance into the program. Applicants will be given an opportunity to confirm ability to attend each session prior to tuition payment. Sessions run January through June. There are nine full-day sessions (all Wednesdays).

Leadership Germantown Application Education & Training: Outline your academic background, training, and continuing education experiences.

Personal Success: What do you consider your greatest achievement (either personal and/or career oriented)?

Involvement: List Community, Civic, Professional, Business, Religious, Social, Athletic, and Other Organizations of which you are, or have been, a member. Attach additional pages if necessary.

Organization Approximate Dates Official Position Held

Accomplishment: What have you accomplished in these activities that you think is important? BE SPECIFIC.

Other Interests: Please list other interests or hobbies.

Leadership Attributes: What characteristics do you have that suggest that you will be a leader in organizations which play a significant role in the community?

Leadership Germantown Application Goals: What do you hope to gain from Leadership Germantown? Be Specific.

Future: What plans have you for future community volunteer service, such as civic clubs and organizations, neighborhood associations, professional groups, boards, commissions, etc.?

How long have you lived in Germantown? (if applicable)

How long have you worked in Germantown? (if applicable)

Are you a registered and active voter? Yes No

Vision: Identify a particular challenge, issue, or problem you feel is critical to the Germantown Area. Explain your concern and possible involvement in the solution of this issue.

Community: In your opinion, what are the strengths of Germantown?

______Signature of Applicant Date of Application

Leadership Germantown Application Return Completed Application to: Chairman of the Board Leadership Germantown 2095 Exeter Road, Suite 80-353 Germantown, TN 38138

Or Scan & email to: [email protected]

Two (2) 50% scholarships may be awarded on a need-only basis. To request consideration, submit a letter identifying the need and attach to this application. Please state whether class participation is dependent on scholarship award. Scholarship eligibility will be decided after class eligibility is determined, and scholarship consideration must be requested when application is submitted.

With your application please remember to include:

 Head shot photo (passport size suitable for publishing)  A one or two paragraph bio (maximum 160 words)  $50 application fee (non-refundable)

Leadership Germantown Application