2016
Powhatan Leadership Institute
Application to Participate
(please print)
Name_____________________________________________________________________________________
First
Middle Initial
Last
Nickname (For Name Tag)
Home Address______________________________________________________________________________
County/City____________________________________________________ Zip ________________________
Phone#____________________________________________________________________________________
(Home)
(Cell)
(Work)
E-Mail ___________________________________________________________________________________
Occupation ________________________________________________________________________________
Employer _________________________________________________________________________________
How did you learn about this program?
__________________________________________________________________________________________
__________________________________________________________________________________________
I will attend as many of these meetings as possible. I understand that missing more than three (3)
scheduled sessions may result in unsuccessful completion of the course.
Signature:_____________________________________________________
$60.00 Registration Fee
Please make check payable to "POWHATAN LEADERSHIP INSTITUTE"
and return your registration fee and completed application by
November 1st, 2015 to:
Powhatan Leadership Institute
ATTN: Treasurer
P.O. Box 418
Powhatan VA 23139
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Name: ______________________________________________
(please print)
Please include a 3 x 5 photo of yourself for the 2016 PLI Class Bios that will be given to each class member.
(If you do not have a photo, we will be taking pictures on Orientation day as well.)
The following individual information is requested for the 2016 PLI Class and will be used solely by the PLI.
This information will be included in each class participant's notebook as a brief biography of each member.
1. Hometown? Where were you born and raised?
__________________________________________________________________________________________
__________________________________________________________________________________________
2. In addition to your hometown, have you lived anywhere else for any length of time? Where? How long?
__________________________________________________________________________________________
__________________________________________________________________________________________
3. How long have you lived in Powhatan?
_______________________________________________________
4. What is/was your occupation?
_______________________________________________________________
5. Do you belong to any association, organizations? What positions have you held?
__________________________________________________________________________________________
__________________________________________________________________________________________
6. What are your interests or hobbies?__________________________________________________________
__________________________________________________________________________________________
7. Personal information you would like to share - married, single, children, grandchildren, area of the county
that you live, etc.?
__________________________________________________________________________________________
__________________________________________________________________________________________
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Name: ______________________________________________
(please print)
8. Please check your voting district:
______ #1 Fine Creek / Subletts
______ #2 Powhatan Station / Graceland
______ #3 Bethesda
______ #4 Powhatan Courthouse / Ballsville
______ #5 Smith's Crossroads / Pineville
9. Why are you taking this class?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
10. To minimize expenses, please tell us if you can download and print out session documents from an email or
internet site or would you require a printed copy?
______ Download documents from an email
______ Download documents from an internet site
______ Download documents from either an email or internet site
______ Printed copy
11. Any additional information you would like to share? (please write on back if needed)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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