Lonoke County Leadership - Online Application

Name	*
Home Address 1	*
Home Address 2
City	*
State	*
ZIP Code	*
E-mail Address	*
Your Name (for a name tag)	*

Employment

Business/Firm Name	*
Business Address	*
City, State, ZIP	*
Business Phone	*
Your Title (as you would want it published/broadcast)	*
Length of Service with present business/organization	*

Organizations and Activities:

List memberships in community, civic, professional, business, religious, social, athletics, and other organizations (in order of value to you) during the past five years. If not applicable, leave blank.

How many hours per month are you currently committed to community, civic, professional, and other organizations and activities? *

0 - 5 hours

6 - 10 hours

11 - 20 hours

more than 20 hours

What do you hope to gain from your involvement in the Lonoke County Leadership Training Program? *

In your judgment, what are the three most important issues facing our county today? Give any recommendations for dealing with these issues. *
Issue #1

Issue #2

Issue #3

Are you a registered voter? *
Yes No

If no, why not?

What other things should the selection committee know about you to make a decision about your application for the Lonoke County Leadership Training Program? *

Name two persons in your community, not related to you, whom the selection committee could contact for additional information about you.

Reference 1

Name	*
Address	*
Phone	*

Reference 2

Name	*
Address	*
Phone	*

Do you have the full support of your employer for the time required to participate effectively in Lonoke County Leadership Training Program? *
Yes No

Tell us something interesting/unique about yourself that most people don't know. *

Please copy and paste an updated bio. Please only include 1 - 2 paragraphs. *

Please provide the name and phone number of person who referred you to our program:

Enter the verification code exactly as shown, using capital and lowercase letters, in the multi-colored box *
Verification Code:

By clicking on the "Submit" button below, you are confirming that the information contained in this application is true and correct to the best of your knowledge. If you have not been contacted within three business days after your submission please contact one of the Steering Committee members.