Leadership Bartlesville Class of XXIX Online Application - Bartlesville Chamber of Commerce

Sponsoring Organization

Nominees for the Leadership Bartlesville program must have the support and commitment of their sponsoring business or organization. The signature of the sponsoring organization is necessary as an indication of support of the nominee’s participation in Leadership Bartlesville, and understanding of the attendance requirements and expense involved.

Sponsoring Organization

Supervisor's Name*

First Last

Supervisor's Email*

Title

Agreement

*

I, hereby grant Leadership Bartlesville, through its designated representative, permission to verify any information contained on the succeeding application. I understand completion of this application does not ensure my acceptance into Class XXIX. To graduate from the Leadership Bartlesville program, I am committed to attending the required Orientation Retreat, Bartlesville Day at the Capitol, and to attend all monthly sessions (see page 1 for dates). No more than 1.5 absences are allowed. I further understand that participation in all Leadership Bartlesville sessions is essential to the learning experience and I may be dropped from the class without a tuition refund and will not graduate if I miss more than 1.5 sessions.

Electronic Signature of Applicant*

First Last

This serves as your signature for the application.

Date

Confidential Application Class XXVIX

First Name

Preferred First Name

Middle Initial

Last Name

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer

Title/Job Responsibility

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you subject for a transfer?

What percentage of your job requires out of town travel?

Cell Phone

Work Phone

Email*

Fax

Birthday

Length of Residence in Bartlesville

Do you anticipate being a resident in the Bartlesville area

5 years
5-10 years
10-15 years

Have you previously applied for a Leadership Bartlesville class?

Yes
No

If yes, when?

Have you ever participated in any other Leadership class?

Yes
No

If yes, where?

If you do not live in Washington County, do you serve on any boards, commissions, or committees within Washington County? Please list.

Preference will be given to those who live in the community and/or who are actively engaged in the community.

Education Background

Begin with high school, then college(s), business or trade schools and/or special training.

Schools

Name and City	Dates (from-to)	Degree/Major

Special Awards, Honors, Prizes for Academic Performance

Extracurricular Activities and Special Honors or Awards for Leadership Activities

Employment History

Account for all periods including military active duty

Employment

Employer	Employee's Responsibility/Title	Dates Employed

What do you consider your highest responsibility, skill or career achievement to date?

Community Service/Activities

What is your major volunteer role at this time?

Organization

Position(s) in the Organization

Describe responsibilities

Please list, in order of importance to you, other civic, religious, social, athletic or other such organization of which you are or have been a member.

Organization	Dates of Membership	Position(s) Held

Please list your professional and business associations and affiliations.

Organization	Dates of Membership	Position(s) Held

How much time each month do you commit to community, civic and professional organizations or other activities?

After completion of Leadership Bartlesville, would you be willing to serve with additional organizations, boards, or civic groups? If so, what subject areas interest you most?

If you have previously not had the time or interest to become actively involved, what conditions have changed that now enable you to see involvement in the community?

General Information

What would you gain by participating in Leadership Bartlesville?

What are your long-range goals; what role do you see yourself in five years from now (whether business, politics, or the community)?

In your opinion what do you feel to be the most significant problem facing the Bartlesville metropolitan area? Why? What do you feel needs to be done concerning this problem?

Commitment

To graduate from the Leadership Bartlesville program, the participant is required to attend the Orientation Retreat, Bartlesville Day at the Capitol, and attend all monthly sessions (see page 1 for dates). No more than 1.5 absence is allowed. This requirement is strictly enforced.

Initial

By giving your initials, you agree to the commitment above.

IMPORTANT: After filling out the form and sending it in, go to this link to sign up for an interview time.

Name

This field is for validation purposes and should be left unchanged.