---

Financial Aid

I will require financial aid
(A small amount of scholarships are awarded to small business, minority, and/or non-profit professionals when funds are available. Candidates who ask for financial aid may be asked for additional information).

Applicants’ quality and depth of response will impact potential selection into the program.

---

I. Personal Data

Full Name:

Perferred Name:

Age:

Gender:

Race:

Place of Birth:

Home Address:

Business Address:

Home Phone:

Work Phone:

Fax:

Email:

Length of Residence in the Raleigh area:

If married, Spouse's Name:

Number of Children:

Names and Ages:

Hobbies:

---

II. Education
(Begin with college(s), advanced degrees, and/or specialized training.)

School Name and Location:

Degree / Major:

Attended School From:

Attended School To:

School Name and Location:

Degree / Major:

Attended School From:

Attended School To:

Special Awards for Academic Performance:
if any

Extracurricular Activities: (Leadership positions held, special honors and awards received during school years.)
if any

 

---

III. Employment

Present Employer:

Service Date:

Type of Organization:

Title or Responsibility:

A. Briefly describe your responsibilities in your employment:

B. List previous employment in reverse chronological order: (Include active military duty.)

Employer:

Title/Responsibility:

Employed From:

Employed To:

 

Employer:

Title/Responsibility:

Employed From:

Employed To:

 

C. What do you consider your highest career achievement to date?

 

D. Business/Professional Affiliations (if any): (Not including civic organizations, public office, or political activities)

Name of Group:

Position Held or Assignments:

Affiliation Start Date:

Affiliation End Date:

 

Name of Group:

Position Held or Assignments:

Affiliation Start Date:

Affiliation End Date:

 

Name of Group:

Position Held or Assignments:

Affiliation Start Date:

Affiliation End Date:

 

---

IV. Community Involvement
(Include community, civic, religious, political, government, social, athletic, or other activities. Do not include business or professional activities. Indicate major role in the organization at this time.)

1a.Organization:

Assignment/Position:

Describe responsibilities:

 

1b.Organization:

Assignment/Position:

Describe responsibilities:

 

2.How do you decide what activities to be involved in?

3. What do you consider your most important accomplishment in one of the listed organizations?

4. Have you been as active in community, civic, professional, and other activities as you would like to be? Why?

5. If you have previously not had the time or interest to become actively involved, what conditions have changed that now enable you to seek involvement in the community?

 

---

V. General Information
(One of the goals of Leadership Raleigh is to build a network of community leaders who can enhance their problem-solving and other leadership abilities through shared perspectives and working together.)

1. What are the three most significant challenges facing the Greater Raleigh/Wake County area today?

2. What are the three most notable opportunities Greater Raleigh/Wake County area has to offer?

3. What do you think needs to be done to develop one of these opportunities or solve one of the challenges?

4. What specific skills/knowledge do you hope to gain from your participation in Leadership Raleigh?

5. How do you plan to apply the knowledge gained in Leadership Raleigh?

 

---

Candidate Program Agreement
I have reviewed the program calendar and agree to meet the requirements of attendance during the program.

Full Name:


Supervisor Contact
(supervisor will be contacted for verification)

Full Name:

Phone: