Applicationx

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
Age Next Jan 1*
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 Age Next Jan 1
Spouse/Guest Gender
Spouse/Guest Race
For the following questions, please limit answers to 150 words. What do you hope to gain from participating in Leadership Georgia?*
What do you feel you can contribute to Leadership Georgia?*
Describe a community project or initiative in which you participated. What was the issue or opportunity? What was your role? What were the results?*
What do you believe is your community's greatest challenge? What, if any, role do you expect to play in helping address this?*
Please share a leadership challenge that you have faced. How did you manage it, and what did you learn?*
Describe your most significant contribution or achievement thus far.*
Community Involvement Activity 1. 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 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.
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. If selected, will you commit to all 5 programs?*
Is your spouse able to commit to all 5 programs?
Headshot Image (at least 800x800, max size 10MB)*
Accepted file types: jpg, png, Max. file size: 10 MB.

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