Allen Lima Leadership - Developing Tomorrow's Leaders Today!

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Personal Data

Name:	,		.	/ /
	Last	First	Middle Initial	Date of Birth

Business Title
Business Name
Business Address
Home Address
Business Phone	( ) -
Home Phone	( ) -
Fax Number	( ) -
E-Mail Address
Years is Lima/Allen County
Gender	Female Male
Ethnicity

Have you previously applied for participation in Allen/Lima Leadership?
Yes No

How did you learn about Allen/Lima Leadership?

Employment

A. Present Employer

Date Hired

/ /

Title/Brief description of responsibility

B. List previous positions held with your present employer and other employment in reverse chronological order.

Brief description of Employer

Title

Responsibility

From - To

C. What do you consider to be the most important accomplishment in your life?

Community Activities/Interests

A. Please list, in order of importance to you, any civic, professional, religious, community, athletic, social, or other organizations of which you are or have been a member.

Organization

Title/Responsibility

From - To

B. What do you consider to be your most important volunteer community service accomplishment in one of the above organizations?

C. What community organizations or service areas are of interest to you to become involved with or participate in as a volunteer?

General Information

A. List in order of significance, three major problems facing the Lima/Allen County area today.

1.
2.
3.

B. What specific recommendations would you make to address the problem you listed in A-1 (above)?

C. Why do you think you should be selected to participate in Allen/Lima Leadership?

What do you hope to gain from your participation in Allen/Lima Leadership?

References

E. List three (3) Personal and/or Professional References:

1.	Name	Title	Organization

Business Phone	Home Phone
( ) -	( ) -

2.	Name	Title	Organization

Business Phone	Home Phone
( ) -	( ) -

3.	Name	Title	Organization

Business Phone	Home Phone
( ) -	( ) -

Education

(begin with high school, college(s), advanced degrees, and/or specialized training)

Name of School

City

Dates attended

Degree

Major

Special Honors and Awards

List any special honors or awards you have received.

Commitment Statement

A. ATTENDANCE
The time commitment is nine all-day sessions October through June. The opening retreat will be a two day session in September. Only one excused absence will be allowed. Participants who fail to fulfill their attendance obligations will be asked to withdraw from the program.

B. TUITION
Tuition is $1150 and is non-refundable after the first class. The participant pays $150, with the remaining $1000 paid by a financial sponsor (the participant's employer or sponsoring organization) or by the participant. A limited number of partial scholarships are available. If accepted, do you wish to apply for tuition assistance? Yes If so, please state the amount requested, and your reason for the request;

$

I understand the goals and commitments of the Allen/Lima Leadership program. If selected, I am willing to attend all the sessions/functions sponsored by Allen/Lima Leadership and devote the necessary time to be a contributing member of the Allen/Lima Leadership class. I understand that if I fail to meet these obligations I will be asked to withdraw from the program.
I agree to the above statement.

I agree to pay $1000 of the Allen/Lima Leadership tuition for the above applicant, if accepted. I understand tuition is non-refundable.

Financial Sponsor Name:
Title/Organization:

I agree to allow my employee to devote the time necessary to be an active member of the Allen/Lima Leadership class, if accepted.

Employer Name:
Title:

Send in a $50 application fee payable to Allen/Lima Leadership
Mail to: Allen-Lima Leadership
144 S. Main Street, Suite 202
Lima, OH 45801

Any questions, please send an e-mail to all@wcoil.com.

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