LSC application

Nomination Form
I would like to nominate the following individual to participate in Leadership SouthCoast’s Class of 2019! Please enter the nominee's information below. Upon receipt of this nomination, LSC will send the nominee an invitation to apply.
Candidate's Name *

First Name Last Name
Employer *
If not currently employed, please type n/a in all employer-related fields.
Position *

Employer's Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer's Phone *

- Area Code Phone Number
Work Email *

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

- Area Code Phone Number

Nominator Information
Name *

First Name Last Name
Organization *

First Name Last Name
Position *

First Name Last Name
Phone *

- Area Code Phone Number
Email *
Would you like your nomination to be anonymous?

Yes, I/we would like to remain anonymous No, you may use my/our organization name
Would you like to sponsor this individual?

Yes No
If yes, please note that tuition for each participant in LSC is $3,200. Sponsoring organizations or individuals are asked to cover $3,050, with the remaining $150 covered by the participant to demonstrate a personal commitment to the program. The tuition covers all program costs and materials. A tuition payment is due by January 31, 2019 unless prearranged with LSC’s Executive Director. The tuition payment must be made by check and is non-refundable.
Tuition Assistance

If you are unable to sponsor this individual, please be aware that LSC has a limited amount of financial assistance available for those candidates who are accepted into the program and demonstrate financial need that would prevent participation. Financial assistance will not be granted for the entire tuition amount. Award amounts are based on the number of requests received and the amount of funds available each year through fundraising. Flexible payment plans may also be arranged. Applications for assistance are confidential and have no bearing on the Selection Committee’s decisions. LSC is committed to ensuring all qualified and interested individuals that are selected into the program have the opportunity to participate.
Thank you for your nomination! The class of 2019 will be selected through a competitive process conducted by a Selection Committee comprised of LSC alumni. Applicants will be notified of the committee’s decision in late November 2019. LSC will select roughly 30 individuals based on criteria including: commitment to civic involvement in the SouthCoast, potential for community leadership, and professional and personal achievement. Diversity is a key goal of LSC. Factors used in determining the final make-up of the class include age, geographic location, employment sector, race, ethnicity, sexual orientation, and gender.
I certify that all information provided here is accurate.
Signature *
Date *
Should be Empty:

Nomination Form

Nominator Information

Tuition Assistance