LCC Application Form

Last Name:
First Name:
Middle Name:
Preferred First Name:
Home Address:
Apt:
City:
State:
Zip:
Work, Live or Both in CC:
Phone:
Business Phone:
Ext:
Business Fax:
Email:
Where would you prefer to receive LCC mailings?

EMPLOYMENT
Company Name:
Address:
City:
State:
Zip:
Present Title:
In Position Since:
Briefly Describe your present job responsabilities and the nature of the work
What do you consider your most significant contribution or achievement related to your work?
Please list business associations or professional organizations in which you have been active
Which of the following categories best describes your present employer?
Other :

CHARTER MEMBERSHIP
Are applying on behalf of a LCC charter member organization, check the appropriate member?
If so, what organization?

EDUCATION
Please begin with high school and list colleges, graduate training and specialized programs
Extracurricular activities; honors and awards:

CIVIC INVOLVEMENT
Please list your volunteer participation in order of importance to you - inlcude public office, civic, religious, political, and other activities.

Note: This information is as important to the selection committee as your professional accomplisments
Please describe briefly one specific example of how you mobilized people to tackle a tough challenge in your community or at work:

LEADERSHIP OPPORTUNITY
If you were given the opportunity to meet with a Cumberland County leader you respect, who would that person be, what would you discuss, and why?

CUMBERLAND COUNTY ISSUES
Please summarize, in the space provided, one significant problem or opportunity facing Cumberland County. Offer recommendations for action.

REFERENCES
Reference 1 - Name, Title, Address, Phone, Known Since.
Reference 2 - Name, Title, Address, Phone, Known Since.

COMMITMENT
The Leadership Cumberland County program takes place during the workday on the first Monday of every month, November through June with the exception of a holiday, if any. Participation in the Opening Retreat/Orientation on September 22 & 23 is mandatory. Participants are expected to attend all Community Learning Days. To graduate, participants may miss no more than one Community Learning Day during the year. Any participant missing more than one day will not be elegible for graduation. Candidates should have the support and commitment of their employer, as indicated by a supervisor's signature below.

Tuition for the 2015 program is $700. Scholarship assistance is available on the basis of need. Admission is without regard to ability to pay.

Check here if you require scholarship assistance, if so,
Half scholarship ($350)
Quarter scholarship ($175)

I understand the purposes and requirements of Leadership Cumberland County. I have my employer's cooperation to participate in the program year. I will devote the time to complete the program and participate in Leadership Cumberland County activities after the program year.
Candidate's Signature:
Employer's Signature:
Employer's Name:

Leadership Cumberland County endorses the concepts of non discrimination and equal opportunity for all, regardless of color, race, religion, sex, national origin, disability, age, place of birth, martial status, or military service.