4601 College Blvd. - Farmington, NM 87402 Phone: 505.566.3264 Fax: 505.566.3687
2016 - 2017 CONFIDENTIAL APPLICATION
All applications will be handled in the strictest confidence.
MISSION STATEMENT
The mission of Leadership San Juan is to identify, enlighten and encourage emerging leaders in diverse backgrounds,
occupations and cultures for the purpose of enhancing the quality of leadership in our communities.
Have you previously applied to and been interviewed for Leadership San Juan?
If so, number of times?
Please Note: Only one member of a household will be selected for the current class.
I. PERSONAL
Mr/Ms.
First Name
Last Name
Home Mailing Address
Home Phone
Birthdate
City
Cell Phone
Ethnicity
(optional)
State
Zip
Email
Do you plan to make San Juan County your
permanent home?
Yes
No
How many years have you lived or worked in San Juan County?
II. EMPLOYMENT
Present Employer
Date of initial employment
Type of Business
Your Title
Business Address
City
Business Phone
FAX
home
office
Zip
Email
Are you subject to transfer with your business/organization?
Preferred contact-MAILING
State
Yes
Preferred contact-PHONE
Briefly describe your current occupational responsibilities:
No
home
cell
office
III. EDUCATION
Please provide the following information. State your educational background. Please include degrees awarded
(college), field of study, professional institutes, other training programs, etc. You may email your resume as an
attachment to [email protected].
IV. CIVIC INVOLVEMENT
List the major civic, business and professional activities in which you have participated during the last five
(5) years. Include offices held, awards and/or special recognitions. Also include elected offices and/or
appointed committee/commission participation.
What is your area of particular interest in community leadership (e.g., education, human services, government,
religion, etc.), and what do you feel you can contribute to the community in this area?
V. GENERAL
In your judgment, what are the two (2) most pressing problems facing San Juan County? Why?
Describe San Juan County twenty (20) years from now.
VI. TUITION
Tuition for Leadership San Juan is ** $750 (this tuition amount is from the current year and will probably
increase for the 2016-2017). A limited amount of funds for tuition assistance will be available for participants in
the program. If you need tuition assistance, fill out the Scholarship Form, save, and then email as an
attachment to [email protected].
A non-refundable deposit of $150 is required if chosen to be a participant. The remainder of the tuition will be
due by August 15, 2016.
VII. REFERENCES
Please provide the names of three business and/or personal references.
Name
Address
Phone
VIII. PARTICIPANTS AGREEMENT
Leadership San Juan requires each participant to attend one session a month from September through May. As a
participant, I am willing to attend all functions sponsored by the program and I understand that attendance is most
important. Missing any combination of 16 hours of session time may result in my dismissal from the program
and my tuition not being refunded. The program may also require some additional time for outside field
experiences.
Will you be able to fulfill this time commitment?
Yes
No
The class will be limited in the number of participants. If you are not selected for this year's class, we encourage you
to reapply next year. Completion of this application does not ensure a candidates acceptance in the class. Selection of
participants will be based upon application, personal interview, and an effort to have a demographically diverse class.
Interviews will be conducted during the month of June.
If selected to participate, I understand and agree to abide by the attendance requirements stated above. Attendance at
the retreat is mandatory (September 9, 10, 11, 2016), and I will be able to attend.
Applicants Signature
Date
My employer understands that participation in Leadership San Juan may require my absence from work for at least one
day per month from September through May.
Employers Signature
Date
You may submit this application in one of three ways:
1) EMAIL - along with supporting documentation to [email protected]:
please save it and email as an attachment
2) MAIL - along with supporting documentation to:
Valerie Wheeler
4601 College Blvd.
Farmington, NM 87402
3) FAX - along with supporting documentation to:
Attention Valerie Wheeler
505-566-3521
Application Deadline: May 15, 2016. Please submit completed application by this date.
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