Application

Application Code*

Please enter the application code received in the email from Leadership Georgia informing you of your nomination.
Full Name*
Last Name*
First Name (for your name badge)*
Current Employer*
Current Title*
Occupation Category*
What are your responsibilities in your current occupation?*
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Residential County*
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Best Email*
Cell Phone*
Business Phone
Date of Birth*
Gender*
Ethnicity*
Years Lived in Georgia*
Years since last move to Georgia, if different
First Time Applicant*
- Yes
- No
If not, enter prior years applied
Current Status*
Spouse/Guest Name (Enter N/A if not applicable)*
Spouse/Guest Current Employer
Spouse/Guest Current Title
Spouse/Guest Residential Address (if different)
Best Spouse/Guest Email
Spouse/Guest Cell Phone
Spouse/Guest Date of Birth
Spouse/Guest Gender
Spouse/Guest Race
What do you hope to gain from participating in Leadership Georgia? (150 words max)*
What do you feel you can contribute to Leadership Georgia? (150 words max)*
What do you believe is your community's greatest challenge? What, if any, role do you expect to play in helping address this? (150 words max)*
Please share about a time when your perspective has been broadened or changed. (150 words max)*
Describe your most significant contribution or achievement thus far. (150 words max)*
Explain your involvement in 3 community activities - civic, business, religious, political or social in nature: indicate name of the organization, describe your responsibilities and roles.
Community Involvement Activity 1.*
Community Involvement Activity 2.*
Community Involvement Activity 3.*
List previous three employments (if applicable) and titles, and describe job duties at each..*
List up to three professional affiliations, organizations or associations you are involved with, along with leadership roles and years involved.
Education: Please include degree awarded and year received, along with name and location or institutions, if applicable. (High School, Undergraduate, Advanced Degrees)*
List significant continuing education experiences.*
List significant activities, awards, offices held.*
Please list names of up to three people who will write letters of recommendation for you. Note that these letters should be emailed directly to selections@leadershipgeorgia.org from the person writing the recommendation. You are strongly encouraged to have 3, but no more than 3, letters.
Would you approve of Leadership Georgia announcing your selection?
If yes, provide name and contact information for your local newspaper
Attending all 5 program weekends is mandatory for you and your spouse/guest. If selected, will you commit to all 5 programs?*
Is your spouse/guest able to commit to all 5 programs?
Headshot Image (at least 800x800, max size 10MB)*
Accepted file types: jpg, png, bmp, jpeg, Max. file size: 10 MB.

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