Leavenworth-Lansing Area Chamber of Commerce
Leadership Leavenworth-Lansing Application

Name _________________________________________(___)_________/____/___
               Last                         First             Middle                Age               Date of Birth

Home Address:_____________________________     Phone:(___)______________

City:_________________     Zip:______     Spouse's Name:_____________________

Business Name & Address: ______________________________________________

City:_________________     Zip:______     Business Phone:(___)________________

Applicant's Email Address: ______________________________________________

Immediate Supervisor's Name & Title: ______________________________________

Immediate Supervisor's Address: _________________________________________

Immediate Supervisor's Phone: ___________________________________________

I acknowledge that I am making a commitment to attend all sessions and will make every effort to do so. I understand graduation is dependent on attendance and that absences will be dealt with on an individual basis.

Applicant's Signature: _________________________ Supervisor's Signature (if applicable):_____________________________

USE ONLY THE SPACE PROVIDED to address the following sections with as much information as you have available, while refraining from listing an award or honor in more than one section. Only a duplicate of this form will be sent to the selection committee.

1. Please state present work responsibilities.
 
 
 
 
 
 
 
 
 
 
 

2. Please list work experience. List job and brief job description. (Limit to last 10 years.)
 
 
 
 
 
 
 
 

3. Please list formal education as well as any educational accomplishments within the field of work. Include degrees awarded and/or professional institutes and training programs attended. (Please include dates.)
 
 
 
 
 
 
 
 

4. Please list present community involvement, listing voluntary, social, business and professional activities. Indicate the scope of your responsibilities with these involvements.
 
 
 
 
 
 
 
 

5. Please list past community involvements (voluntary, social, business and professional activities) and briefly indicate your participation in each activity. (Limit to past 10 years)
 
 
 
 
 
 
 
 
 

6. Please list awards or special recognition that you have received through your involvement in professional and community activities.
 
 
 
 
 
 
 
 
 

7. Why do you want to participate in the Leadership Program?
 
 
 
 
 
 
 
 

8. What do you see as the Future of the Leavenworth-Lansing Area?
 
 
 
 
 
 
 
 
 

9.  Please list your personal interests and/or hobbies outside of your profession.
 
 
 
 
 
 
 
 
 
 

10.  NOTE: Letters of recommendation should be written to describe why you have potential as a leader in the Leavenworth-Lansing area and how your leadership will be applied in the community. Only the three recommendation letters you list below will be accepted for use in the final selection process. Please have the letters mailed directly to: Leavenworth-Lansing Area Chamber of Commerce, P. O. Box 44, Leavenworth, Kansas 66048. Recommendation letters are to be received no later than close of business August, 5, 2004.

List those who will provide a letter of recommendation:

______________________    __________________    _________________________________________
Name                                      Title                                     Address

______________________    __________________    _________________________________________
Name                                      Title                                     Address

______________________    __________________    _________________________________________
Name                                      Title                                     Address
 

Leadership Leavenworth-Lansing tuition is $275 for the class of 2005. Payment of tuition is due prior to the first class.  Partial Scholarships are available to cover a portion of the tuition.  If you are requesting a partial scholarship, that request with justification should be in a separate letter accompanying this letter.

I am interested in receiving Leadership Leavenworth-Lansing scholarship assistance in the amount of $ _________.
My letter requesting scholarship assistance is enclosed.

Return this form by mail (NO FAXES) no later than close of business August 5, 2004, to:
Leadership Leavenworth-Lansing
Leavenworth- Lansing Area Chamber of Commerce
P. O . Box 44
Leavenworth, Kansas 66048

A Program of Your Leavenworth-Lansing Area Chamber of Commerce
 

Leavenworth-Lansing Area Chamber of Commerce
518 Shawnee, P.O. Box 44,  Leavenworth, Kansas 66048,  (913) 682-4112, FAX: 682-8170, E-mail
Representing the Communities of Leavenworth, Lansing and Fort Leavenworth.

Revised: 05/19/05.