LLC Application

LEADERSHIP LEXINGTON COUNTY

Application

Title
First Name
Middle Name
Last Name
Preferred Name
PO Box / Street
City
State
Zip Code
Home Address
Phone
Fax
Business Address
Phone
Fax
Email
Pager / Cell
Preferred Contact Method	Home Phone Business Phone Email Cell Phone

PROFESSIONAL INFORMATION

Employer
Title
The responsibilities of your position:

Ninety-percent attendance at sessions is required for graduation and attendance at the entrance retreat is mandatory. In addition, participants will be required to take part in enrichment activities and a class project. Please indicate your acceptance of this commitment below.

You and your employer's signature check box must be checked to indicate you both understand the following: {1} you (the applicant) can make this attendance commitment and you have the support of your employer and {2} the selection process consists of this application and interview.

Employee Signature Check Box

Employer Signature Check Box

EDUCATIONAL INFORMATION:

High School	Location	Diploma/Year
College	Location	Diploma/Year
Educational accomplishments or recognition:

Community activities in which you have participated include {List activates in order of importance}

Organization	Activity	Role	City	Year
Organization	Activity	Role	City	Year
Organization	Activity	Role	City	Year
Organization	Activity	Role	City	Year

If selected for Leadership Lexington County, I anticipate that I will benefit personally and professional in the following ways:

List specific qualifications that make you a viable candidate for participation in Leadership Lexington:

List three significant advantages Lexington County has to offer residents and employees.

1)
2)
3)

List three specific challenges Lexington County is facing today:

1)
2)
3)

I believe I will make the following contributions to my community over the next five years:

PLEASE NOTE: Please follow-up with a phone call to (803) 359-8515 ext. 111 to be sure your application has been received.
YES I acknowledge that I should follow up at the number above to make sure my application has been received.

FINANCIAL INFORMATION

Tuition in the Leadership Lexington County Program is $395.00. Please send your check made out to Leadership Lexington County to:

Lexington County Extension Service
605 West Main St., Ste 109
Lexington, SC 29072

Your check will be held until notification of acceptance and not deposited before December 1, 2008.