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 PhoneAge Next Jan 1* 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 Age Next Jan 1 Spouse/Guest GenderFemaleMaleSpouse/Guest RaceAfrican AmericanAsianCaucasianHispanic / LatinoTwo or more / OtherFor 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?YesNoIf 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?*YesNoIs your spouse 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.