427 York Street . Vallejo, CA 94590
707.644.5551 . Fax 707. 644.5590 . www.leadershipvallejo.org
MISSION STATEMENT:
Leadership Association of Vallejo is a personal development program designed to motivate participants to develop and enhance the quality of their leadership skills. Graduates will be equipped to effectively identify the needs of Vallejo and address them via positive community involvement. Based on this initial application, a certain number of candidates will then be selected to participate in an oral interview process. After the oral interview process, individuals will be selected to participate in the upcoming class.
Fields with a
*
are required
1. Residence
*
Last
*
First
Middle
*
What Name or nickname do you use?
*
Street Address 1
Street Address 2
*
City
*
State
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CA
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DC
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MA
MI
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MO
MT
NE
NV
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NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
ZIP
Home Phone
*
Area/Country Code
*
Number
Fax
*
Area Code
*
Number
Cell
Area Code
Number
*
Email
2. Employment
*
Present Employer or
Business Name
Hire Date
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(mo/da/year)
Business Address
City
Zip
phone
(
)
Fax
(
)
*
Email
Type of Business
Position/title
A.
Briefly Describe
Your Responsibilities
B.
Previous Employment
Employer
Title or Responsibilites
Location
From/To Dates
3.
Education
Some College
AA
Baccalaureate
Masters
A.
Name and City of College
Dates
Degree
Major
B.
Apprentice or Certificate Program Completed
Dates
Certificate
4.
ORGANIZATIONS/ACTIVITIES/COMMUNITY INVOLVEMENT
A.
Please list, in order of importance to you, three community, civic, professional, business, religious, social, athletic, and/or other organizations in which you have participated. Please describe the nature of your participation, responsibilities, accomplishments, and awards/recognition you received.
1.
Name of Organization
Dates of Involvement
Highest Position Held
Elected/Appointed
Elected
Appointed
Describe
2.
Name of Organization
Dates of Involvement
Highest Position Held
Elected/Appointed
Elected
Appointed
Describe
3.
Name of Organization
Dates of Involvement
Highest Position Held
Elected/Appointed
Elected
Appointed
Describe
B.
If you have not participated in community activities, what conditions have changed that now enable you to seek involvement in the community and in what specific activities will you seek involvement?
C.
Describe how you believe your participation in the Leadership Association of Vallejo Program will enhance your ability to become personally involved in activities and/or organizations in Vallejo. Please explain:
D.
Years you have lived/worked in Vallejo
?
Do you expect to be living in and actively involved in the Vallejo area in 5 years? Explain in detail as to why you see yourself actively involved, in what areas, and why in the Vallejo area?
5.
GENERAL
A.
Describe any other community activities which exhibit your service in Vallejo.
B.
In your judgment what are two pressing problems facing the Vallejo area today and why?
C.
What do you hope to gain through your participating in Leadership Association of Vallejo that may not have been addressed in the previous questions?
6.
REFERENCES
Please provide the names of three current business and/or personal references that can be contacted by the Selection Committee.
1.
Name
Address
Phone
2.
Name
Address
Phone
3.
Name
Address
Phone
7.
TUITION
Tuition in the amount of $1150 is non-refundable. A personal financial commitment of $150 is required; the balance of the fee may be paid by any club, organization, business, employer, or the participant. One-half of the Leadership Vallejo tuition is due prior to the first day of the program. The balance is due in full by December 31, and can be paid in installments.
Please indicate how your tuition balance will be paid
Employer
Participant
Other
Other (Please specify)
8.
FINANCIAL AID APPLICATION
I would like to apply for financial aid.
Yes
No
9.
Final Agreement
Participant’s commitment:
Full participation in this program is critical. If selected, I make a commitment to meet all time, financial, and participatory requirements of the program.
I agree.
Employer’s commitment (if not self-employed):
I understand the importance of full participation of the applicant, and if he/she is selected to participate, then I, as the Employer, will provide release time from work and will help him/her meet the requirements.
I agree.
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