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Application for Leadership

LEADERSHIP PIKE COUNTY APPLICATION

A program sponsored by the Pike County Chamber of Commerce
PRINT THIS PAGE(s) AND FILL OUT THE NECESSARY INFORMATION. MAIL OR FAX THE COMPLETED APPLICATION TO THE PIKE COUNTY CHAMBER OFFICE AT
787 HAMBLEY BLVD., PIKEVILLE, KY 41501; FAX: (606) 432-7295
APPLICATION DUE SEPT. 1, 2010 by 5:00 PM

A P P L I C A T I O N

Please type or print in ink each section fully. Applications must be signed by both applicant and employer/sponsor and received in the Pike County Chamber office no later than Tuesday,

September 1, 2010. We suggest you make a copy of your completed form.

Date completed and mailed___________________

I. PERSONAL DATA

Name___________________________________________________________________

Last First Middle Name Called

*Age____________ *Gender______________ * Race __________

Place of Birth _______________________________ Yrs. in Pike Co. Area ___________

Home Address (Not PO) ___________________________________________________

____________________________________________ Magisterial District __________

City State Zip

Home Phone_________________ Email _____________________________________

Business Name ___________________________________________________________

Address_________________________________________________________________

Street City State Zip

Occupation______________ Business Phone ________________ Fax_______________

If Married, Spouse’s Name _________________________________________________

Names & Ages of Children__________________________________________________

________________________________________________________________________

Do you anticipate being a long-term resident of Pike County?___________

Hobbies & Interests _______________________________________________________

_______________________________________________________________________

*This information is used to assure class diversity.

II. EDUCATION

(Begin with high school; then college, business, trade school, or other specialized training.)

Name of School & Location Dates (from/to) Degree Major

_________________________________ _________________ ________ _______

Extracurricular Activities; Special Honors & Awards; Leadership PositionsDuring School Years

_______________________________________________________________________

________________________________________________________________________

III. EMPLOYMENT

Current Employer_______________________________ Date Began_______________

Current Title or Responsibility______________________________ Since___________

Previous employers (list in reverse chronological order and account for all periods including military active duty)

Employer Title or Responsibility From/To

______________________ _____________________________________________ _______________

______________________ ____________________________________________ _______________

______________________ ____________________________________________ ________________

What do you consider your highest responsibility, skill or most significant career achievement thus far? ________________________________________________________________

________________________________________________________________________

Please list business/professional affiliations you have been a member of__________________

________________________________________________________________________

IV. COMMUNITY INVOLVEMENT

Organizations and Activities

Please list, in order of importance to you, up to five communities, civic, religious, social, athletic, political, and other organizations to which you belong or did belong.

ORGANIZATION DATES OF POSITIONS HELD

MEMBERSHIP

_____________________________________________________________________________________

What was accomplished in any of these activities that you consider significant? Please explain your role(s). _____________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

How many hours each month do you commit to community, civic, professional, and other

organizations and activities? __________ Have you been as active in such activities as you would like to be? ________ If not, what major barriers have blocked your desired participation?

______________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

What kind of volunteer activities would you like to become active with in the future? _________

______________________________________________________________________________

V. GENERAL

What do you expect to gain from your Leadership Pike County experience?__________________

_____________________________________________________________________________________

In your judgment, what are the three most important challenges facing Pike County today? Explain why.

_____________________________________________________________________________________

VI. BIOGRAPHY

In the space below, please write a brief bio which can be distributed to the class.

EXAMPLE: As Vice President of Widget, Inc., Thacker directs her company’s R&D operations. She has been active in various community initiatives. She is treasurer of Stone Heritage Corporation and serves on the board of Pikeville/Pike County Tourism Commission. She is a member of Sharondale Baptist Church.

_____________________________________________________________________________________

VII. ATTENDANCE

The Opening Session of LEADERSHIP PIKE COUNTY will meet in October at the Breaks Interstate Park. The session is mandatory. All other sessions of Leadership Pike County will meet all day the second Thursday of each month, November through May. To graduate from the program, you can miss no more than two sessions. Will your schedule (work and personal) allow you to make this commitment? ________

Graduation will be in conjunction with the Pike County Chamber’s Annual Meeting held in July.

VIII. EMPLOYER/SPONSOR & APPLICANT COMMITMENTS

TUITION FEE TO BE PAID IF SELECTED: $300

If accepted into the Leadership Pike County program, you will be billed for the tuition fee of $300 which covers all program costs, excluding transportation to and from session sites. We encourage participants to ask their employers to sponsor their tuition fees. Tuition fee must be paid by October 1st and is not refundable.

If you need financial assistance, please call to request a scholarship application. This will not be a part of the selection process; however, the completed form must be in by September 1, 2010.

EMPLOYER COMMITMENT

This applicant has the approval of this organization and our full support which includes the time required to participate in the program.

____________________________________

Firm

_________________________________________________________________________________________________________

Signature Date

APPLICANT COMMITMENT

I understand the purposes of the Leadership Pike County program and if I am selected I will devote the time and resources necessary to complete the program. The October session is mandatory (no exceptions will be made). Even though emergencies do arise, any participant missing more than one of the remaining six sessions, for whatever reason, may be asked to withdraw from the program and no portion of the tuition shall be refunded. Arriving more than one hour late or leaving more than one hour early will be considered an absence. I understand the above commitments and agree to be bound by them in signing this application.

________________________________________________________________________

Applicant Signature Date

IX. REFERENCES

Exactly three recommendation letters must be submitted. It is the responsibility of the applicant to contact the reference and request a recommendation be submitted. Such letters should describe the applicant’s potential as a future community leader and how his/her leadership will benefit the community. Reference should mail letter directly to: LEADERSHIP PIKE COUNTY, 787 Hambley Boulevard, Pikeville 41501. These must be received by September 1, 2010.

Name/Title ___________________________________________________________

Business Address ______________________________________________________

Phone ____________________________ Email _____________________________

Name/Title ___________________________________________________________

Business Address ______________________________________________________

Phone ____________________________ Email _____________________________

Name/Title ___________________________________________________________

Business Address ______________________________________________________

Phone ____________________________ Email _____________________________

X. SUBMITTING APPLICATION

APPLICATION SHOULD BE MAILED TO:

LEADERSHIP PIKE COUNTY

C/O Pike County Chamber of Commerce

787 HAMBLEY BOULEVARD

PIKEVILLE, KENTUCKY 41501

DEADLINE FOR ALL APPLICATIONS AND ALL REQUIRED MATERIALS TO BE RECEIVED IN OUR OFFICE IS SEPTEMBER 1, 2010, 5:00pm.

All applications are subject to confidential evaluation. A geographical mix of residents is a consideration in selection of the class. If you are not selected to participate in this Leadership Pike county class, your application will be retained by the committee to consider for later enrollment.

Questions? Please contact the Pike County Chamber of Commerce

Phone: 432-5504 Fax: 432-7295 Email: brad.hall@pikecountychamber.org

Website: www.pikecountychamber.org

Thank you for your interest in Leadership Pike County.