Leadership

CHAMBER

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2012-2013 Adult Leadership Application
(Deadline is June 15, 2012)

Criteria For Candidate Selection Includes:

Leadership Skills

Willingness and Ability to Assume Greater Community Responsibility

Diverse Background and Experience

Community Involvement

Download and print a PDF of this application

*PERSONAL DATA*
Name
Title
Name of Employer
My company IS a current member of The Chamber of Commerce of St. Joseph County. My company IS NOT a current member of The Chamber of Commerce of St. Joseph County.
Business Address Line 1
Business Address Line 2
City
State
Zip
Business Phone
Business Fax
E-mail
Home Address Line 1
Home Address Line 2
City
State
Zip
Home Phone
Home Fax
Home E-mail
Number of years in the Michiana community
*EDUCATION & SPECIALIZED TRAINING*
High School
University(s)
Degree(s)
Specialized Training (Institutes, Seminars, Trade Schools)
*EMPLOYMENT HISTORY (Beginning with the most current position)*

*CURRENT COMMUNITY INVOLVEMENT*
Provide name of organization and position held for volunteer, civic and community activities.
*MISCELLANEOUS QUESTIONS*
What has been your most satisfying community activity? Why?

In your opinion, what is this community's most significant asset or challenge and how would you choose to influence it?

What community leadership role would you like to fulfill five years from now?

How did you learn about the Leadership Program and why are you interested in participating?

Leadership South Bend/Mishawaka strives to select a class that is representative of our community. To help us achieve this goal, please explain how you can help contribute to the diversity of the class.

Sponsoring Person
Sponsoring Organization
I understand that completion of this form does not guarantee placement in the 2012-2013 Leadership Program. The deadline for applications is June 15, 2012. 2012/2013 tuition is $1,895, or $1,795 if payment and application are received before June 15. Applicants will be notified of selection no later than July 1, 2012. I represent a small business or small not-for-profit. Please consider my application for tuition assistance.

	The Chamber of Commerce of St. Joseph Countyy 401 E. Colfax Ave., Suite 310 South Bend, IN 46617 574.234.0051 FAX 574.289.0358 info@sjchamber.org
	© Copyright 2004 The Chamber of Commerce of St. Joseph County