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Community Leadership Program Application
  1. I. Personal Data
  2. Personal Address:(*)
    Please select your personal address
  3. First Name(*)
    Please enter your first name
  4. Middle Name(*)
    Please enter your middle name
  5. Last Name(*)
    Please enter your last name
  6. Preferred Name (nickname)(*)
    Please enter your preferred
  7. Home Address(*)
    Please enter your home address
  8. City(*)
    Please enter your city
  9. State(*)
    Please select a state
  10. Zip Code(*)
    Please enter a valid zip code
  11. Home Phone(*)
    Please enter your home phone number
    ex: (765) 446-8105
  12. Cell Phone
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  13. Home E-mail address(*)
    Please enter a valid e-mail address
  14. Date of Birth(*)
    Please enter your date of birth
    ex: 01/01/1980
  15. Length of Time in Greater Lafayette(*)
    Please enter how long you\'ve lived or worked in Lafayette
    ex: 6 years, 7 months

  16. II. Employment
  17. Present Employer/Business Name(*)
    Please enter your present employer
  18. Title/Responsibility(*)
    Please enter your title
  19. Business Mailing Address(*)
    Please enter your business mailing address
  20. Business City(*)
    Please enter your business city
  21. Business State
    Please select a state
  22. Business Zip Code(*)
    Please enter a valid business zip code
  23. Business Phone(*)
    Please enter your business phone number
    ex: (765) 446-8105
  24. Business Fax
    Please enter your business fax
    ex: (765) 446-8105
  25. Business E-mail address(*)
    Please enter a valid e-mail address

  26. Employment History: List previous employment; may include active military duty (list most recent job first).
  27. Last Employer
    Please enter your last employer
  28. Title/Responsibility
    Please enter your title
  29. From/To Dates
  30. Previous Employer
    Please enter your last employer
  31. Title/Responsibility
    Please enter your title
  32. From/To Dates
  33. Previous Employer
    Please enter your last employer
  34. Title/Responsibility
    Please enter your title
  35. From/To Dates

  36. Enter any additional employment information below.
  37. Invalid Input

  38. III. Education: In chronological order, list schools, advanced studies, and/or specialized training.
  39. Name of School
    Please enter the name of your school
  40. City
    Please enter the city of your school
  41. From/To Dates
  42. Degree/Major
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  43. Name of School
    Please enter the name of your school
  44. City
    Please enter the city of your school
  45. From/To Dates
  46. Degree/Major
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  47. Name of School
    Please enter the name of your school
  48. City
    Please enter the city of your school
  49. From/To Dates
  50. Degree/Major
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  51. Enter any additional educational information below.
  52. Invalid Input
  53. IV. Volunteer Involvement: Please list, in order of importance to you, three community organizations or causes in the Greater Lafayette area for which you are or have recently been an active volunteer. Please note any leadership positions held. If you are new to Greater Lafayette, please list volunteer activities from your previous community.
  54. 1. Organization(*)
    Please enter the name of the organization
  55. Approximate Dates of Service
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  56. Volunteer Responsibility
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  57. 2. Organization(*)
    Please enter the name of the organization
  58. Approximate Dates of Service
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  59. Volunteer Responsibility
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  60. 3. Organization(*)
    Please enter the name of the organization
  61. Approximate Dates of Service
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  62. Volunteer Responsibility
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  63. B. If you have previously not had time or interest to become actively involved, what conditions have changed that now enable you to seek community involvement?
  64. Invalid Input

  65. C. Describe a personal or volunteer responsibility or accomplishment, and what makes it significant to you.
  66. Invalid Input

  67. V. Community Action Teams: Every Leadership Lafayette class member will participate on a Community Action Team (CAT) to plan and implement a community project. The following information will help to identify potential CAT projects. In your opinion, what are three issues facing the Greater Lafayette community or region today?
  68. 1. First community or regional issue.
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  69. 2. Second issue
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  70. 3. Third issue.
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  71. B. What could a Community Action Team do to address one of these issues?
  72. (*)
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  73. C. Why do you want to participate in the Leadership Lafayette program? How do you expect to use your Leadership Lafayette experience?
  74. (*)
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  75. D. Is there any other information about yourself which you feel would be of interest to the Selection Committee? (i.e. Personal strengths, special interests, etc).
  76. (*)
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  77. VI. Recommendations : Please list two individuals who are knowledgeable about your leadership performance and potential, and your volunteer experience. A letter of recommendation is welcome and may be forwarded separately by mail, fax or email to Leadership Lafayette.
  78. Name
    Please enter a name
  79. Phone
    Please enter a phone number
    ex: (765) 446-8105
  80. Organization
    Please enter your last employer
  81. Title
    Please enter your title
  82. Name
    Please enter a name
  83. Phone
    Please enter a phone number
    ex: (765) 446-8105
  84. Organization
    Please enter your last employer
  85. Title
    Please enter your title

  86. VII. Finances: Tuition for Leadership Lafayette is $1,550.00. Businesses and organizations are encouraged to sponsor employees or members by paying their tuition. Partial scholarships are also available. Leadership Lafayette is committed to providing development opportunities to citizens who are committed to community service and leadership regardless of ability to pay. However, scholarship funds are limited and requests will be considered on the basis of demonstrated need. Applications for program participation are considered without regard to scholarship needs.

    Tuition Payment:

  87. A. My employer or sponsor
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  88. Amount agreed to pay: $
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  89. B. I agree to pay $
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  90. C. Other sponsor
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  91. Amt. agreed to pay: $
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  92. D. I wish to apply for a partial scholarship of $
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  93.  
  94. E. I wish to apply for a scholarship from:


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       (You must be a member of this organization.)
  95. If you checked other, please specify
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  96. Please explain why you are requesting tuition assistance (all information is confidential).
  97. Invalid Input
  98. Tuition invoice should be sent to:
  99. Full Name
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  100. Title
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  101. Company
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  102. Address
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  103. City
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  104. State(*)
    Please select a state
  105. Zip Code
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  106. If applicable, additional tuition invoice should be sent to:
  107. Full Name
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  108. Title
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  109. Company
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  110. Address
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  111. City
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  112. State(*)
    Please select a state
  113. Zip Code
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  114. VIII. Applicant Commitment

    I understand that:

    • • I am expected to serve and strengthen my community upon completion of this program.
    • • Although some employers have an internal selection process, submitting my application does not guarantee me a position in the class.
    • •When more applications are received than there are spaces available in the class, the Selection Committee may be unable to select some candidates even though they may have excellent credentials. These candidates are encouraged to reapply.
    • • Assignments outside the class sessions will be required. If selected as a participant, I am willing to attend all sessions and complete assignments sponsored by the program.
    • • Leadership Lafayette may request a limited criminal history check. If you have ever been convicted of or pled guilty to a felony or misdemeanor, please describe the circumstances in a separate document mailed or e-mailed to our offices.
    • • I am granting permission to the Selection Committee to discuss the information on this application with people who are knowledgeable about my ability, potential, and demonstrated interest in the community and to hold the Selection Committee harmless concerning the selection process and decision.
    • • Upon completion of the program and group project, I will be eligible to earn Continuing Education Units from Purdue University.
    • • The application must be accompanied by a $15.00 application fee payable to Leadership Lafayette which is non-refundable. This fee is waived if the application is submitted online.
    • • If applicable, I agree to pay the tuition as indicated above.
    • • I certify that the information provided on this application is true and complete and agree that falsified information or significant omission may disqualify me from further consideration by the Selection Committee and may be considered justification for dismissal from the Leadership Lafayette Program if discovered after my selection.
  115. (*)
    You must signify your acceptance of the above commitment by checking this box.
  116. IX. How did you learn about Leadership Lafayette? Please check appropriate area(s).
  117. Invalid Input

  118. For additional information, please call Leadership Lafayette at (765) 269-5860, fax (765) 269-5899, or email LLstaff@leadershiplafayette.org. Please check the information on your application before submitting.