Course Application Form

Please note: A fee of $25.00 is required to submit this application.

APPLICANT INFORMATION

* First Name

* Last Name

* E-Mail Address

* Mailing Address

* City

* State

* Zip Code

* Phone - Home

Phone - Work

* Phone - Cell

* Have you participated in and/or graduated from another leadership Program? If “Yes” where? Please answer below.

Yes
No

Participation City

Participation State

Participation Year

VOLUNTEER POSITIONS, ACTIVITIES, AND ACCOMPLISHMENTS

* Please list dates, organization, positions held, duties, accomplishments and supervisor.

EMPLOYMENT HISTORY (Last 5 years)

* Please list dates, employer, positions held, duties, accomplishments and supervisor.

Educational Background

* Please list institution, name & location, # years, grad. year, major course of study and degree

LEADERSHIP INTERESTS, GOALS & OBJECTIVES

* Briefly discuss your leadership interests, goals and objectives.

* Describe the community or civic subject that interests you the most.

* What would you most like to contribute to the Mesa Community?

* What do you expect to gain from participation in the Mesa Leadership Program?

MESA’S COMMUNITY CHALLENGES

* Briefly discuss three opportunities and/or problems facing the Mesa community today. Your answer to this question helps us to focus on those areas of interest to our class.

References

References are required from two people who can be contacted to provide knowledge of your qualifications as a Mesa Leadership applicant. Please do not use family members as references. It’s preferred that references are in the local area.

* 1. Name

* 1. Home Phone

* 1. E-Mail

* 2. Name

* 2. Home Phone

* 2. E-Mail

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