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* BUSINESS PHONE:
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| AGE (Voluntary):
20-24 |
| List the number of years you have lived in Lackawanna County:
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Have you previously applied for participation in Leadership Lackawanna?
Yes
No
If yes, when
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| How did you learn about the Leadership Lackawanna Program?
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EDUCATION
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List your educational background, including high school, college(s), advanced degree(s), specialized training
programs or professional institutes. |
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EMPLOYMENT
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Present Employer:
Starting Date:
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| Type of Business:
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| Title or Position:
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| Briefly describe your present responsibilities:
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| List previous employment, including active military duty, in reverse chronological order: |
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| Indicate what, in your estimation, has been your most significant career advancement to date:
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| List your business/professional affiliations/organizations: |
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COMMUNITY INVOLVEMENT
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| List your community, religious, governmental, social, and/or athletic activities over the last five years. Indicate
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| Describe the type(s) of community activities in which you would like to become involved:
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List any of your professional or community-service awards/honors:
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LEADERSHIP LACKAWANNA/COMMUNITY INTEREST INFORMATION
One of the goals of Leadership Lackawanna is to build a corps of community leaders who can utilize its talents and problem-solving abilities through shared perspectives and networking.
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Indicate what you hope to accomplish through your participation in Leadership Lackawanna:
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Indicate a personal goal that you have yet to accomplish:
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Tell us why Leadership Lackawanna should be interested in you:
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TUITION / SCHOLARSHIPS
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Tuition for the Leadership Lackawanna Program is $950.
A deposit of $100 is required upon acceptance into the program.
Full and partial scholarships are available on a limited basis.
If you would like to request tuition assistance,
please indicate the amount and explain the reason. |
Amount Requested:
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REFERENCES
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| N.B. Each reference must be someone other than a family member. Only one (1) reference from your supervisor/
employer can be listed. |
List three (3) people who may be contacted about your qualifications to participate in Leadership Lackawanna:
Name/Title Address Phone Number |
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| N.B. The Selection Committee reserves the right to contact the references during the selection process. |
PARTICIPANT’S COMMITMENT
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To graduate from Leadership Lackawanna, the participant is required to attend the day-long sessions scheduled one week
day per month, from October through June. The Orientation in September is also mandatory.
I understand the purposes of Leadership Lackawanna, and if I am selected, I commit to attend the Orientation and all the
monthly sessions. As a participant, I fully understand that should I miss more than two sessions, for whatever reason, I
may be dismissed from the program with no portion of my tuition refunded. I understand that I will be required to work on a
group project in addition to the monthly sessions. I further understand that this is a competitive selection process, and due
to space limitations, not all applicants can be selected.
I understand the above commitments and agree to be bound by them in signing this application. |
Applicant’s Signature Date
SPONSOR’S AGREEMENT
(To be completed unless nominee is self-proposed)
A nominee for Leadership Lackawanna must have the support and commitment of his/her employer, as well as his/her sponsoring organization (if different than employer). The signatures of the employer and/or sponsoring organization (where appropriate) are required as an indication that the employer and/or sponsoring organization is/are in complete support of the nominee’s participation in Leadership Lackawanna.
Please indicate the support of the employer and/or sponsoring organization by checking the appropriate box(es). Financial support indicates your willingness to pay the applicant’s tuition associated with participating in the Leadership Lackawanna Program. Release time support indicates your willingness.
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EMPLOYER (If applicable)
Financial Support
Release Time Support
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| Company:
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| Address:
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| Phone:
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Approving Officer Name and Title:
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Approving Officer Signature:
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| Date:
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SPONSORING ORGANIZATION (If applicable)
Financial Support
Release Time Support
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| Organization
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| Address:
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| Phone:
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Approving Officer Name and Title:
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Approving Officer Signature:
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| Date:
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FINAL REMINDERS
Complete each section of this application. Please be as thorough as possible.
A check payable to Leadership Lackawanna, for the non-refundable $15 processing fee, must accompany the completed application.
Applications must be received at the Leadership Lackawanna office, 222 Mulberry Street, P.O. Box 431, Scranton, PA 18501-0431, by 4:30 PM, Monday, March 31. Applicants will be notified of the Selection Committee’s decision by June 2, 2008.
Your application is not complete unless it is accompanied by the non-refundable $15 processing fee, your signature, and the signature(s) of your employer and/or sponsoring organization.
If the applicant does not have the support of his/her employer/sponsoring organization to participate in the program, please explain the reason on a separate page.
Any additional information must be typed on plain white paper and attached to this application. A copy of applicant’s resume may be included with the application.
Any questions should be directed to Nicole Barber at 570-342-7711 ext. 125 or by email to nbarber@scrantonchamber.com. |
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