<p>Please utilize Microsoft Word to complete this form. </p><p>Applicant Name:</p><p>Relationship to applicant:</p><p>___Personal</p><p>___Professional</p><p>How long have you known this individual? ___</p><p>Applicant readiness for leadership development</p><p>To what extent do you agree or disagree with the following statements as they pertain to the individual applying for the Leadership Forum/ADLP with 5 being strongly agree and 1 being strongly disagree:</p><p>5 4 3 2 1 Attending the Forum/ADLP this year makes sense for this applicant</p><p>The applicant has shown a commitment to developing and growing as a leader</p><p>The applicant is open to self-reflection and willing to make improvements </p><p>There is potential for this person to occupy future leadership positions for which attending the Forum/ADLP will prepare them</p><p>Based on the applicant’s trajectory, the applicant will put what they learn at the Forum/ADLP into action following their participation</p><p>Open ended questions:</p><p>What are this candidate’s two or three main leadership strengths?</p><p> Please discuss a specific example of how this candidate has demonstrated leadership to date If this candidate is selected to participate in the ADLP/Leadership Forum what two or three areas could be strengthened by their participation in this program? </p><p>Where do you see this applicant utilizing the skills taught in the ADLP/Leadership Forum programs? </p><p>Academic Dermatology Leadership Program (ADLP) Applicants only Do you feel that this applicant has the time to dedicate to the ADLP and the development of a mentoring relationship, including attending the required sessions at the Annual and Summer Meetings and the Leadership Forum?</p><p>Please share any additional information you feel the committee needs to know about this applicant.</p><p>Overall ranking:</p><p>Please rank the applicant on a scale of 1-10 with 10 being Self-aware and willing to grow and 1 being Inflexible and lacks insight.</p><p>1 2 3 4 5 6 7 8 9 10 Inflexible and lacks insight Self-aware and willing to grow ______Signature Date</p><p>______(Name – please print or type)</p><p>Please return to Jaime Lewen via fax (847-240-8719) or email as a PDF attachment to [email protected] by September 15, 2017.</p>