Leadership East Region Application Question Title * 1. Personal Data Full Name * Employer/Business * Home Address * City/Town * State/Province * ZIP/Postal Code * Personal Email Address Business Email Address * Phone Number * Question Title * 2. Position/Title Question Title * 3. Business Address Question Title * 4. Business Phone Question Title * 5. Sponsoring Business or Organization (if applicable) Question Title * 6. Contact /Title with Sponsoring Organization Question Title * 7. Contact's Business Phone/Email Question Title * 8. Contact's Business Phone/Email BACKGROUND Email a copy of your resume or CV, including a brief description of your current responsibilities to leadership.eastregion@gmail.com Question Title * 9. Complete the following statement: I consider my most important career achievement to be.... PROFESSIONAL, CIVIC, AND PERSONAL INVOLVEMENT Question Title * 10. List notable activities, programs, and events in which you have participated during the past five years. Include any offices held, certificates earned, and awards or recognition received. OBJECTIVES FOR PARTICIPATION Question Title * 11. Describe what you expect to gain from the program and how you anticipate using the experience in your professional, civic, and personal life. AREAS OF INTEREST Question Title * 12. Identify several current issues and opportunities within the East County region and expand on the one that most interests you. REFERENCES Question Title * 13. Provide the names and contact information for two or more professional and/or personal references with knowledge or your qualifications who may each be contacted by the program Steering Committee. 1. 2. 3. Submit
