Online Application Form

Your Information
Name:
Home Address:
Home Phone:
Home E-mail:
Preferred Name for Name Badge:
Length of Residence in the Augusta Area:
Spouse's Name:

Your Business
Business Name:
Your Title:
Business Address:
Business Phone:
Business Fax:
Cell:
Business E-mail:
Where do You Wish to Receive correspondence?	Home Business
Have you previously applied for Leadership Augusta?	Yes No
If yes - when?

Your Education
Name of School:
Dates (from/to):
Degree:
Major:

Name of School:
Dates (from/to):
Degree:
Major:

Name of School:
Dates (from/to):
Degree:
Major:

Community and Professional Development
Organization Name:
Dates of Involvement (from/to):
Hours Volunteered per Month:
Describe Activities:

Organization Name:
Dates of Involvement (from/to):
Hours Volunteered per Month:
Describe Activities:

Organization Name:
Dates of Involvement (from/to):
Hours Volunteered per Month:
Describe Activities:

Why do you think it's important to be involved in community organizations?


Employment
List employment in reverse chronological order beginning with current position. Include active military duty.
Employer:
Location:
Title/Responsibility:
Dates (from/to):

Employer:
Location:
Title/Responsibility:
Dates (from/to):

Employer:
Location:
Title/Responsibility:
Dates (from/to):

General Information
What do you believe is the role and responsibility of a community leader?


What do you feel are your strengths as a leader?


What do you hope to gain from participation in Leadership Augusta?


Is there anything additional you would like the selection committee to know in considering you for the program?


Personal References
All applicants are required to submit two (2) personal references. Personal references must be submitted in the space below. Letters of recommendation, newspaper clippings, etc. will not be considered by the selection committee. Your application will not be considered complete until the personal references have been received. Please indicate below the persons who will submit references:

Name:
Organization:
Title:
Phone:

Name:
Organization:
Title:
Phone:

Optional Information:
Sex:
Race:
Date of Birth:
Hobbies/Interests:

Tuition & Financial Assistance Tuition for each participant is $750.00. Once selected, participants must pay tuition in full prior to the first session. Tuition is nonrefundable, non-transferable and the responsibility of the class member, but many employers pay all or part of the tuition for employee participants. Contact your employer for more information. Tuition should not be a barrier to participation!
I would like consideration for a partial scholarship in the amount of:	$

Commitment
I understand the commitment required of all selected participants of the Leadership Augusta Program
Date: