Signature Course application

Name

First NameLast Name

Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home/cell phone

Area CodePhone Number

Work phone

Area CodePhone Number

E-mail

Business/organization name

Business title

Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of birth

Years in Lima/Allen County?

Have you applied for the ALL class previously?

How did you hear about ALL?

Emergency contact

First NameLast Name

Home/cell number

Area CodePhone Number

Work number

Area CodePhone Number

Please list any food allergies or special meal concerns

Current employment: Please list present employer, date hired & responsibility

Previous employment: List positions with your employer and other recent employment, including employer, title and dates

List in order of importance to you, any civic, professional, religious, community, athletic, social or other organizations of which you are or have been a member.

List organization, title/responsibility, dates:

Education/honors: List high school, advanced degrees, and/or specialized training:

List any honors you have received:

What do you consider to be the most important accomplishment in your life?

What do you consider to be your most important volunteer/community service accomplishment from one of the above organizations?

What community organizations or service areas are of interest to you, to become involved with or participate in?

List three major problems facing the Lima/Allen County area today:

What specific recommendations would you make to address a problem you listed above?

What do you hope to gain from your participation in Allen Lima Leadership's Signature Course?

References: List three personal and/or professional references - Name, title, organization, phone, email:

Commitment Statement

A. Attendance: The time commitment is a required two-day retreat in September and nine all-day sessions October through June. Only one excused absence will be allowed. Participants who fail to fulfill their attendance obligations will be asked to withdraw from the program.

B. Tuition is $1,150 and is non-refundable after the first class. A limited number of partial scholarships are available. If accepted, do you wish to apply for tuition assistance?

If so, please state the amount requested and your reason for the request:

C. I understand the goals and commitments of the Allen Lima Leadership Signature Course. If selected, I am willing to attend all sessions/functions sponsored by ALL and devote the necessary time to be a contributing member of the class. I understand that if I fail to meet these obligations, I will be asked to withdraw from the program.

Name

First NameLast Name

Date

MonthDayYear

Employer/Sponsor

Our policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual orientation, age, or disability.

Send your completed application with a $50 nonrefundable application fee payable to Allen Lima Leadership, 144 S. Main St., Suite 202, Lima, OH, 45801. Application deadline: Aug. 5.

Signature Course application

Community activities/interests