Leadership Genesee Confidential Application 2010-11 Session
Instructions
• Complete, sign, and send only the application pages. Print and mail to: Dale Weighill,
Resource Genesee, Leadership Genesee, 1401 S. Grand Traverse, Flint, MI 48503.
(This application cannot be electronically submitted from this page.)
• Applications must be signed by candidate and employer or candidate's financial sponsor.
•Include $200 deposit to hold your spot and qualify for the September 1 rate.
• *If you wish to apply for a scholarship, a letter indicating the reason and amount requested
must be included with your application.
This will be used for the directory.
Application Date
Name
(Dr., Rev., Mr., Ms., Mrs.) First Name Last Name
Preferred Name for Name Tag
Job Title Employer
Work Address
Street Suite/PO Box City Zip
Bus. Phone Bus. Fax
Voice Mail/Direct Dial Bus. E-Mail
Cell Phone: Other
Home Address
Street Address Apt. # City Zip
Home Phone Home Fax
Home E-Mail Birth date
Live in Genesee County? No. of yrs.
Work in Genesee County? No. of yrs.
Ethnicity: Asian Pacific African American Caucasian
Hispanic Native American
Other: I do not wish to disclose this information_____
Shirt Size: ______ Female Male
Do you have any special dietary needs or will you require special accommodations? Yes No
Dietary and/or Accommodations needed: _______________________________________________________________
Work Supervisor: Name Email
Phone
Type of Organization/Business which best describes the areas in which you presently work/serve.
Advertising/Marketing/Public Relations
Arts
Automotive
Banking/Financial/Investment
Chamber of Commerce/Trade Association
Clergy/Religious
Communications (Telephone/Cellular/Mobile)
Computer & Related
Design & Construction
Education K-12 Higher Ed
Environmental
Government
Health Care (Large Institutions)
Human Services
Insurance
Interior Design & Furniture
Legal
Manufacturing
Media (Newspaper/Publishing/Television/Radio)
Non-Profit/Community Volunteer
Personnel & Employment Services
Real Estate & Property Management
Recreation
Retail & Sales
Small Business
Utility
Other
Personal Information
Write a brief biography for inclusion in the Leadership Genesee Class of 2010 – 2011 Directory
List previous employment in reverse chronological order (include active military duty)
Employer City/State Title/Responsibility From -To
Professional/Business Associations and Community Involvement
Organization Position(s) or Assignments Hours per month
What do you consider your most important civic contribution and why?
What specific skills / knowledge do you hope to gain from your Leadership Genesee experience?
How have you demonstrated a commitment to diversity in the workplace and/or community affairs?
Civic Information
In your opinion, waht are the three most significant challenges facing Genesee County?
1.
2.
3.
In your opinion, what are the three most notable opportunities Genesee County has to offer?
1.
2.
3.
How did you hear about Leadership Genesee?
Media
Alumni (please name):
Personal Contact (please name):
Other
References
Please list two references who can be contacted for additional information.
Name Title Organization Phone
1.
2.
Employer/Sponsoring Organization Commitment
The Applicant has our full support including the time required to participate in the program.
Upon receipt of invoice, our organization will pay the tuition for the Applicant.
Name
(Please Print)
Firm/Organization
Bus. E-Mail
Work Address
Street Suite/PO Box City Zip
Payment
___Enclosed is the full amount
___Enclosed is the $200 deposit
___Please invoice for the remaining amount
___Please invoice monthly until balance is paid
Please return completed application, $200 Deposit to:
LEADERSHIP GENESEE c/o Resource Genesee
1401 S. Grand Traverse, Flint, MI 48503