Complete only those items that apply to you. Leave others blank. Typed applications are preferred. If you would like an electronic version of the application, please call 229-776-7718.

BASIC INFORMATION

* denotes a required field.
Name :
Present Employer :
Title :
Business Address :
City :
State :
Zip :
Phone :
Fax :
* Email Address :
Home Address :
Male/Female :	...Select... Male Female
Spouse's Name :
Spouse's Occupation or Employer :
Mailing Address for LWC materials :
PROGRAM PARTICIPANTS
What do you hope to gain from participating in Leadership Worth County?
In your opinion, what are the three most pressing issues facing Worth County today?
1.
2.
3.
EMPLOYMENT AND PROFESSIONAL AFFILIATIONS
Check all that apply to your position/company.
Business & Industry Government Labor Health Religion Social Service Media Agriculture Education Medical Law Other (name)
Briefly describe your responsibilities in your employment?
Please indicate how your present position relates to Worth County?
What do you consider your most significant contribution or achievement related to your position so far?
Please include civic organizations, public office and/or political activities.
Name of Group Position Held/Assignments Period of Affiliation
EDUCATIONAL BACKGROUND
For each of the following, please include degree awarded and year received, along with name and location of institution.
High School
Undergraduate
Advanced Degree(s)
Other
List activities, offices and recognition for special contributions:
Significant continuing education experiences:
Do you have full support of your employer for the time and tuition fee of $125 required to participate in the LWC Program?
YesNo
Name (Print):
Date :
Signature :
Signature of Supervisor/Employer :