Feb 1, 2017 - Cell Phone: ... _____ ______. (city). (state). (zip). Work Phone: ... A Microsoft Word document is preferr
Clinton Area Chamber of Commerce Leadership Institute 2017 Student Application
Part 1 – General Information This information will be used for Leadership Institute purposes ONLY. Your information will not be shared with anyone outside of the program. You will receive correspondence regarding class information, curriculum updates, upcoming events, and collaboration opportunities following graduation. PERSONAL First name: ___________________ Last Name: _______________________________ How many years have you lived or worked in the Clinton area? ____ Date of birth: ___/___/___ Home address: ___________________________________________________________ ___________________, _____ (city)
__________
(state)
(zip)
Home Email (optional): ____________________ Cell Phone: ______________________ EMPLOYMENT (current position) Organization: ________________________________ Title: _______________________________________ Occupation: __________________________________ Work Address: _____________________________________________________________ ___________________, _____ (city)
(state)
__________ (zip)
Work Phone: _______________________
Work email:
______________________
Part 2 – Essay Questions This is the most important part of the application. This is where you have the opportunity to tell your story. As you answer these questions, give careful thought about how you can explain contributions, opinions, and thoughts. Keep in mind that the Selection Committee will review many applications. The content of your answers should give committee members a good idea of your commitment to leadership and to the Clinton area. Please answer the following essay questions in a separate document and submit the document along with this application. A Microsoft Word document is preferred. 1. Tell us about your past and present leadership roles in civic, professional or service organizations, and how your work impacted the organization. 2. If you have not had the time or interest to become actively involved in community activities, please state why. 3. What particular strengths and experiences would you bring to the Leadership Institute program? 4. What do you feel are the most significant issues facing the Clinton area today, and, in your opinion, how should they be addressed? 5. Why do you wish to participate in Leadership Institute?
Please send the completed application, along with your attached essay question responses, to
[email protected]. We will stop accepting applications for consideration after 5PM on Wednesday, February 1st, 2017. Class is limited to 25 students If you have any questions regarding the Leadership Institute, please contact the Clinton Area Chamber of Commerce. Clinton Area Chamber of Commerce 721 South 2nd Street Clinton, IA 52732 563.242.5702
Application for the Leadership Institute Class of 2017 Signature Page For: Email: Phone:
_________________________________
_________________________________ _______________
In order to complete the application process, please print this page, sign it, then email or mail it to: Leadership Institute c/o Clinton Area Chamber of Commerce 721 South 2nd Street Clinton, IA 52732 Phone: 563-242-5702
[email protected]
Leadership Institute participants are expected to attend all sessions and fully commit to activities and assignments that aid in the learning process. This is a learning experience that requires a strong commitment by the participant and the participant's employer. YOU AND YOUR EMPLOYER MUST SIGN, DATE AND EMAIL THIS PAGE BEFORE THE DEADLINE TO COMPLETE YOUR APPLICATION. Deadline is 5PM on the 1st of February 2017. Applications received after this date will not be considered. All applicants will be notified of their selection status by mid-February, 2017. If accepted, an invoice ($525 payable to the Clinton Area Chamber of Commerce) will be sent along with a letter notifying the applicant of their participation in the program. Thank you for your interest in Leadership Institute! Contact the Clinton Area Chamber of Commerce if you have questions.
__________________________________________ Applicant’s Signature
_______________ Date
__________________________________________ Employer’s Signature
_______________ Date
