Leadership Lackawanna

CONFIDENTIAL APPLICATION
FOR THE 2008/2009 PROGRAM YEAR
(Leadership Lackawanna is a program of The Greater Scranton Chamber of Commerce)

INSTRUCTIONS
-TYPE OF PRINT NEATLY IN BLACK INK-
-YOU MUST COMPLETE EVERY SECTION OF THIS APPLICATION-
(Please be as thorough as possible).

The Selection Committee bases its decision on the information provided by the applicant and references. Try to limit your answers to the space provided. If necessary, continue your typed responses on plain white paper and attach them to this form. The quality and appearance of the materials are taken into consideration.
A copy of your resume may be included with the application. You can download a printable copy of the application from here

The application must be signed by both the candidate and his/her employer/sponsoring organization. Only the candidate’s signature is required in the case of a self-proposed nomination/application.

If the applicant does not have the support of his/her employer/sponsoring organization to participate in the program, please explain the reason(s) on a separate page.

A check payable to Leadership Lackawanna, for the non-refundable $15 processing fee, must accompany the completed application.

Completion of the application does not ensure a candidate’s acceptance into the 2008/2009 program.

Class size is limited. The candidate must either live in or work in Lackawanna County.

THE COMPLETED APPLICATION AND ALL ADDITIONAL INFORMATION
MUST BE RECEIVED
AT THE LEADERSHIP LACKAWANNA OFFICE BY:
4:30 PM ON MONDAY, March 31, 2008

Personal Data

First Name: *M.I

Last Name *

HOME ADDRESS:

HOME PHONE: *

BUSINESS PHONE:

FAX:

EMAIL: *

BUSINESS/ORGANIZATION:

BUSINESS/ORGANIZATION ADDRESS:

JOB TITLE:

AGE (Voluntary): 20-24

25-34

35-54

55 and over

List the number of years you have lived in Lackawanna County:

Have you previously applied for participation in Leadership Lackawanna?

Yes
No
If yes, when

How did you learn about the Leadership Lackawanna Program?

EDUCATION

List your educational background, including high school, college(s), advanced degree(s), specialized training
programs or professional institutes.

Name and Location of School	Dates	Degree(s)	Major's

EMPLOYMENT

Present Employer:

Starting Date:

Type of Business:

Title or Position:

Briefly describe your present responsibilities:

List previous employment, including active military duty, in reverse chronological order:

Employer	Title/Responsibility	Period of Service

Indicate what, in your estimation, has been your most significant career advancement to date:

List your business/professional affiliations/organizations:

Name of Group	Position(s) Held	Period of Service

COMMUNITY INVOLVEMENT

List your community, religious, governmental, social, and/or athletic activities over the last five years. Indicate

Describe the type(s) of community activities in which you would like to become involved:

List any of your professional or community-service awards/honors:

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.

Indicate what you hope to accomplish through your participation in Leadership Lackawanna:

Indicate a personal goal that you have yet to accomplish:

Tell us why Leadership Lackawanna should be interested in you:

TUITION / SCHOLARSHIPS

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:

REFERENCES

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

N.B. The Selection Committee reserves the right to contact the references during the selection process.

PARTICIPANT’S COMMITMENT

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.

EMPLOYER (If applicable)

Financial Support

Release Time Support

Company:

Address:

Phone:

Approving Officer Name and Title:

Approving Officer Signature:

Date:

SPONSORING ORGANIZATION (If applicable)

Financial Support

Release Time Support

Organization

Address:

Phone:

Approving Officer Name and Title:

Approving Officer Signature:

Date:

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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