LEADERSHIP MONADNOCK 2015/2016 APPLICATION Application Deadline: September 18, 2015 Please complete the following: Personal Name: _____________________________________________________________________ Home address: _____________________________________________________________ Business address: ___________________________________________________________ Home or Mobile telephone:
_________________________________
Business telephone: _________________________________________ Email: _____________________________________________________
Current Employment Current employer and title: __________________________________________________________ Responsibilities:
References (personal or business) * * * Application continues on back page
Organizations and Activities: In order of importance to you, please list up to five organizations of which you are or were a member. You may wish to include civic, professional, business, religious, social, athletic or other organizations. Please use an additional sheet, if necessary! Organization
Dates of Membership
Position held/accomplishments
Your Views On a separate sheet, please briefly answer the following:
Why did you become involved with the organization that you listed as the most important to you? What have you learned from your involvement? If you haven’t previously been able to involve yourself in community life, what has changed to allow more involvement now? What do you hope to gain if you are selected for Leadership Monadnock? In your opinion, what are the three most pressing problems facing the Monadnock region today? Please choose one problem and recommend an approach for resolving it.
Please read before signing: Program candidates: Leadership Monadnock brings together individuals with a wide range of backgrounds and experiences who have a strong interest in community leadership. Participants are selected annually. Special attention is directed toward creating a diverse and energetic group that is representative of the Monadnock Region. Application procedure: please send your completed application to Leadership Monadnock, 48 Central Square, Keene, N.H. 03431. Total cost is $850. Financial aid may be available for a limited number of individuals. Application deadline is Friday, September 18, 2015. Selection process: All applications are reviewed by the Selection Committee. Notification of selection status will be communicated shortly after the application deadline. As program costs are incurred in advance, tuition fees will only be refunded on a prorated basis for meals alone. Thank you for applying to the Leadership Monadnock program. For more information, please email Susan Newcomer, Leadership Monadnock Director:
[email protected] or call the GKCC at 3521303. Your signature indicates you have read and understand the information above.
Signature____________________________________
Date _______________________
