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*AccountingAgriculture/FarmingConstructionEconomic DevelopmentEducationEntrepreneur/Small BusinessFinancial ServicesForestryGovernmentGovernment ElectedGovernment RelationsHealth ServicesHigher EducationHuman ResourcesInsuranceLaw/JudicialLaw/Large FirmLaw/Small FirmLaw/StateManufacturingMediaMedical/HealthcareNon-Profit/NGOPublic Relations/MarketingPublic ServiceReal Estate/DevelopmentTelecommunicationsUtilityWhat are your responsibilities in your current occupation?*Residential Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Residential County*ApplingAtkinsonBaconBakerBaldwinBanksBarrowBartowBen HillBerrienBibbBleckleyBrantleyBrooksBryanBullochBurkeButtsCalhounCamdenCandlerCarrollCatoosaCharltonChathamChattahoocheeChattoogaCherokeeClarkeClayClaytonClinchCobbCoffeeColquittColumbiaCookCowetaCrawfordCrispDadeDawsonDecaturDeKalbDodgeDoolyDoughertyDouglasEarlyEcholsEffinghamElbertEmanuelEvansFanninFayetteFloydForsythFranklinFultonGilmerGlascockGlynnGordonGradyGreeneGwinnettHabershamHallHancockHaralsonHarrisHartHeardHenryHoustonIrwinJacksonJasperJeff DavisJeffersonJenkinsJohnsonJonesLamarLanierLaurensLeeLibertyLincolnLongLowndesLumpkinMaconMadisonMarionMcDuffieMcIntoshMeriwetherMillerMitchellMonroeMontgomeryMorganMurrayMuscogeeNewtonOconeeOglethorpePauldingPeachPickensPiercePikePolkPulaskiPutnamQuitmanRabunRandolphRichmondRockdaleSchleyScrevenSeminoleSpaldingStephensStewartSumterTalbotTaliaferroTattnallTaylorTelfairTerrellThomasTiftToombsTownsTreutlenTroupTurnerTwiggsUnionUpsonWalkerWaltonWareWarrenWashingtonWayneWebsterWheelerWhiteWhitfieldWilcoxWilkesWilkinsonWorthBusiness Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best Email* Cell Phone*Business PhoneDate of Birth* Gender*FemaleMaleEthnicity*African AmericanAsianCaucasianHispanic / LatinxTwo or more / OtherYears Lived in Georgia* Years since last move to Georgia, if different First Time Applicant* Yes No If not, enter prior years applied Current Status*MarriedEngagedSingleSpouse/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 PhoneSpouse/Guest Date of Birth Spouse/Guest GenderFemaleMaleSpouse/Guest RaceAfrican AmericanAsianCaucasianHispanic / LatinoTwo or more / OtherWhat 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)*Describe a community project or initiative in which you participated. What was the issue or opportunity? What was your role? What were the results? (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?YesNoIf yes, provide name and contact information for your local newspaper 2024 Program Dates: January 18th-20th, March 7th-9th, April 25th-27th, September 5th-7th, and November 7th-9thAttending all 5 program weekends is mandatory for you and your spouse/guest. If selected, will you commit to all 5 programs?*YesNoIs your spouse/guest able to commit to all 5 programs?YesNoHeadshot Image (at least 800x800, max size 10MB)*Accepted file types: jpg, png, Max. file size: 10 MB.