I. PERSONAL DATA
Name: _______________________________________ First name or nickname preferred: ______________________
Home address: ___________________________________________________________________________________
Business address: _________________________________________________________________________________
Home or cell phone: _____________________________ Business phone: ____________________________________
E-mail address: ___________________________________________ Fax: ____________________________________
Preferred method of contact:
Cell phone
Business phone
e-mail
Real estate specialty (check all that apply):
Residential
Commercial
Resort
Appraisal
International
Buyer Brokerage
Brokerage Management
Land
Other ____________________________________________________________
Real estate designations earned: _____________________________________________________________________
Salesperson
Broker
Years Licensed: ______
REALTOR® Member Since: __________
Hobbies:
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II. EDUCATION
Indicate the highest level of education attained.
GED
High School
Trade School
Bachelor’s Degree
Master’s Degree
Doctorate Degree
Other ____________________________________________________________________
Provide the following information for degrees:
School
Degree
Major
Date
Degree Earned
Extracurricular Activities (Leadership positions held, special honors and awards received during school years):
Please specify any formal leadership training (with a local or state REALTOR® association, community leadership
program, military program, etc.)
Name of Sponsoring Organization
Course Title
Year of Completion
Briefly describe an incident or activity that has had the most impact on your development as a leader so far:
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III. WORK EXPERIENCE
Present firm name: ________________________________________________________________________
Position: _______________________________________________ Since (month/year): ________________
Briefly describe your job responsibilities:
List previous work experience starting with most recent prior to real estate (include active military duty):
Organization/Firm
Title/Responsibility
What do you consider your highest career achievement to date?
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Dates
IV. REALTOR® ASSOCIATION INVOLVEMENT
List any involvement with your local association of REALTORS®
Name of Association
Position held or assignment
Date of service
List any involvement with your state association of REALTORS®
Name of Association
Position held or assignment
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Date of service
List any involvement with the NATIONAL ASSOCIATION OF REALTORS®
Position held or assignment
Date of service
Describe any involvement you may have had in REALTOR® public policy issues (e.g.; Calls to Action, RPAC, fundraising,
hill visits, political campaign activity):
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V. COMMUNITY INVOLVEMENT
List community, civic, religious, political, governmental, athletic, social, or other areas of active involvement:
Organization
Assignment/Position
Responsibilities
What do you consider your most important accomplishment in one of the above organizations? Why?
What specific skills/knowledge do you hope to gain from your participation in the Leadership Academy?
If selected, what leadership opportunities do you plan to seek in your personal/business life, community or REALTOR®
Associations? How do you believe this will benefit your personal/business life, community or REALTOR® Associations?
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VI. GENERAL INFORMATION
Why do you want to participate in this program?
In your opinion, what are the three most significant challenges facing the real estate professional today?
What are your leadership aspirations and how do you expect the Leadership Academy of Connecticut and Rhode Island
can help you achieve them?
How did you hear about the Leadership Academy?
State AE
Local AE
Friend
Website
Brochure/Flyer
Other – please explain: ______________________________________________________
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VII. COMMITTMENT
To graduate from the Leadership Academy of Connecticut and Rhode Island, a participant must commit to attend all three
sessions and complete all homework assignments. Dates and locations are set for (but may be subject to change):
March 28-30, 2011 – Lakeville, CT
June 14-15, 2011 – Newport, RI
September 14-15, 2011 – Westbrook, CT
Once accepted, the applicant will receive further details on exact locations, times and agendas for each retreat.
I understand the purpose of the Leadership Academy of Connecticut and Rhode Island and if I am selected, I will
devote the time and resources necessary to complete the program. If an emergency should arise, I must
immediately notify my State Association of my absence from all or part of any retreat. Participants missing more
than one session within any of the three total retreats (as listed above), for whatever reason, may be asked to
withdraw from the program and no portion of the application or tuition fees shall be refunded. I understand the
above commitments and agree to be bound by them in signing this application.
Applicant Name (print): _________________________________________________
Applicant Signature:
_________________________________________________
Date:
______________________
VIII. TUITION
Payment of the $250 application fee must accompany all applications.
Check Enclosed (payable to C.A.R.)
MasterCard
Visa
Amex
Account # ____________________________________ Expiration Date: ___________ CVC Code*: ____________
*Your Card's Verification Code (for American Express it's a four digit code printed on the front of your card, for MasterCard and Visa it's a three digit
code printed on the back of your card). This code is required to process your order.
Name on Card: ________________________________________________________
Billing Address: ________________________________________________________
City: _____________________________ State: _______ Zip: __________________
Print Form
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