LEADERSHIP Philadelphia
Application for the Core Class of 2017
Due: May 13, 2016
Note: Applications are accepted and reviewed on a rolling basis, so it is to your advantage to apply early.
Personal Information
First Name
Middle Name
Last Name
Preferred Name
Job Title
Organization
Contact Information
WORK
HOME
Street Address
Street Address
City, State, ZIP
City, State, ZIP
Phone
Phone
Email
County of Residence
Cell (optional)
Education
Degree
School
Major
Year
Leadership Experience
Current or Prior Leadership Experience
Current or Prior Community Activities
1.
Commitment
Why are you interested in participating in the LEADERSHIP Core program?
2.
What types of community issues concern you and your organization?
3.
Are you able to attend all sessions? 9/15, 9/16, 10/13, 11/10, 12/15, 1/12, 2/9, 3/9, 4/13, 5/11, & 6/8
4.
____Yes
____No, I have a potential conflict on _____________
Have you enclosed the $500 non-refundable application fee? Note: Checks should be made payable to: LEADERSHIP Philadelphia
____Yes
____No, I will call 215-893-9999 to pay by credit card.
Note: The remaining tuition balance of $7,500 is due no later than July 15, 2016.
Sponsor Endorsement
To be completed by someone who has knowledge of your potential
Full Name of Sponsor:
Sponsor Email:
Check one:
My Sponsor Endorsement is enclosed
My Sponsor Endorsement is being sent directly under separate cover ASAP
Applicant Signature: ___________________________________________
Date___________________
Mail your completed application to: LEADERSHIP Philadelphia, 123 S. Broad Street, Suite 2044, Philadelphia, PA 19109
Email to: Angela Tillar [email protected]
or
LEADERSHIP Philadelphia
Application for the Core Class of 2017
Due: May 13, 2016
Note: Applications are accepted and reviewed on a rolling basis, so it is to your advantage to apply early.
Sponsor* Endorsement
This sponsor endorsement is for:
Nominee Name
Nominee Company
Nominee Immediate Manager
Manager Title
Manager Email
Sponsor Information
Full Name
Job Title
Organization
Work Address
Email
Relationship to Nominee
Nominee Endorsement
1.
Why are you nominating this candidate?
2.
Which of his/her specific leadership skills could benefit from further development?
3.
What do you want this person to get out of the program?
Who is responsible for paying this individual’s tuition?
Name
Company
Sponsor’s Signature: _________________________________________
Date:___________________
*Sponsors are LEADERSHIP alumni or other professionals who are qualified to recommend the applicant.
Please return this form to your nominee to enclose with his/her application or send directly to:
Liz Dow, CEO
LEADERSHIP Philadelphia
123 S. Broad Street, Suite 2044
Philadelphia, PA 19109
Fax: (215) 893-9363 Email: [email protected]
We appreciate your assistance in this process.