Application – Lead Virginia

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Application

Before you submit the application below, please be sure to have your résumé, issue description and application fee ready.

The deadline to apply for the LEAD VIRGINIA class of 2012 is Jan. 15.

Personal contact information

Title:
First name:
Middle name:
Last name:
Maiden name:
Street address:
Street address:
City:
State:
ZIP code:
Home phone:
Cell phone:
Recommended or
referred by:

Professional contact information

Employer:
Position or title:
Street address:
Suite:
City:
State:
ZIP code:
Phone:
Fax:
E-mail:
Website:
Assistant’s name:
Assistant’s phone:
Assistant’s e-mail:
Briefly describe your company or organization, including the sector (public or private business, government, education, nonprofit or other profession) and type (i.e., banking, utility, marketing, military, higher education, law or community services).

Demographic information

I live in a(n):
I work in a(n):
Age:
Years in Virginia:
Family (spouse, children or significant):
Please describe your race or ethnic background (optional):

Community and leadership education

Have you completed a community leadership program or other leadership education or training? If so, please list the program(s) and year(s) completed and note your volunteer or leadership roles.
How are you currently serving in your community, your region or the Commonwealth? List organizations and positions held.

Résumé, curriculum vitae or biographical sketch

Upload document:

Scholarship assistance

Would you like scholarship assistance?
If yes, how much assistance do you need?
Reason for the request:

Issue description

Describe your personal views on the following topic: What are the two most pressing issues or challenges facing Virginia today? Explain why and offer recommendations for approaching and solving these challenges. The suggested length of response is no more than one-half page.
Upload document:

Statement of Commitment

Attendance at the opening session, April 19-21, 2012 is mandatory. Attendance at all other programs is strongly urged. Participants who miss more than two days will be asked to withdraw.
I understand LEAD VIRGINIA's attendance policy and will participate in all programs to the best of my availability.

Signature:

After the application is submitted, you can pay the application fee through Paypal.

LEAD Virginia | 707 E. Main Street, Suite 1035| Richmond, Virginia, 23219
Phone: (804) 644-LEAD (5323)| Fax: (804) 644-0062
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