CONFIDENTIAL
APPLICATION FOR LEADERSHIP OTTAWA COUNTY
Please type or print in black ink
I. PERSONAL INFORMATION
Name:
_____________________________________________________________________________
Last
First
Middle
Preferred Name:
__________________________________ Gender: ______ Date of Birth:
_____________
Home Address:
______________________________________________________________________________
__Preferred Mailing
Address?
Home Phone:
__________________ Spouse’s Name
______________________________________
E-mail address:
_________________________________________________
___Preferred Email
Address?
II. EMPLOYMENT
Present Employer:
__________________________________________________
Business Address:
_________________________________________________________________________
__Preferred Mailing
Address?
Work Phone:
___________________ Fax: ____________________ Email Address:
_____________________
___Preferred Email Address?
Job Title:
_________________________ Responsibilities:
_________________________________________
Professional title: (Dr.,
Rev., etc) ____________________________
III. EDUCATION
|
Name/City of
School
From To Degree
_____________________________________ _______ _______
_______________________________
_____________________________________ _______ _______
_______________________________
_____________________________________ _______ _______
_______________________________
Special
Awards/Honors:
___________________________________________________________________
_______________________________________________________________________________________
Other Certifications or Training
Source of
Training: ________________________________________ Date:
_________________________
Source of
Training: ________________________________________ Date:
_________________________
Source of
Training: ________________________________________ Date:
_________________________ |
IV. COMMUNITY SERVICE
Volunteer and leadership
role(s) at this time (include service club and nonprofit board membership):
- Organization:
_________________________________________________
Position:
_____________________________________________
Responsibility:
_____________________________________________________________________
- Organization:
_________________________________________________ Position:
_____________________________________________
Responsibility:
_____________________________________________________________________
- Organization:
__________________________________________________Position:
___________________________________________
Responsibility:
_____________________________________________________________________
How much time do you spend
as a volunteer in a typical month? _______________________________________
In what kinds of volunteer
activities would you like to become active in the future?
_________________________________________________________________
_____________________________________________________________________________________________________________
V. GENERAL INFORMATION
|
What do you feel
are the two most significant opportunities or problems facing Ottawa
County?
|
|
1)
__________________________________________________________________________________
2)
__________________________________________________________________________________ |
What specific skills/knowledge do you hope to develop by your participation
in Leadership Ottawa County?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
VI. RECOMMENDATIONS
SPONSOR
(Person financially supporting your
participation) This candidate
has my full support to participate in Leadership Ottawa County.
Name: _____________________________
Title: ___________________________ Organization: _________________________
Address:
__________________________________________________________________________________________________
Signature:
____________________________________________________________
VII. COMMITMENT
To graduate from Leadership Ottawa County a participant is expected to
attend 85% of the 9 formal monthly sessions and participate in field
study activities (e.g. class community project, book review, board visit).
A class kick-off and orientation will be held in August. Candidates will be
notified prior to the kick-off.
Classes will meet the second Wednesday of each month, September through May from
1:00 p.m. until 9:00 p.m.
Graduation Ceremony and Dinner will be held the 4th Wednesday of May
at 6:00pm.
VIII. TUITION
Tuition for each participant is $650.00. If selected, payment is due before the
opening session. Extended payment plans may be arranged with the Board.
Limited financial assistance (up to one-half of tuition) may be available for
those candidates who demonstrate a clear financial need. If you wish tuition
assistance, please enter the amount requested and reason for the request.
Check enclosed for
$650.00:_______ Extended payment plan
requested:________
Financial Assistance Requested: _______
Reason: ____________________________________________________________
IX. AGREEMENT
I understand and share the goals of the Leadership Ottawa County program. If
selected, I will devote the required time to fulfill the commitments identified
above and I will either pay my tuition in full or make other arrangements before
the opening session.
Signature:
X_____________________________________ Date: __________________
X. CLOSING INSTRUCTIONS
SEND: Completed application and
check.
(Make
checks payable to Leadership Ottawa County)
MAIL TO: Leadership Ottawa
County, c/o Port Clinton Chamber of Commerce 110 Madison Street,
Port Clinton,
Ohio 43452
QUESTIONS: Call the Port Clinton
Chamber of Commerce at 419-734-5503 or OSU Extension at
419-898-3631 or 1-800-322-4159.