Kettering Leadership Academy Application

BACKGROUND INFORMATION
Name * Required
First Middle Last
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone * Required
Business Phone
Cell Phone
Fax
Preferred Email
Employer
Title
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
# of years you have lived in Kettering
# of years you have worked in Kettering
EDUCATION
Please list schools attended, area of study, and degrees/diploma received. Please include any professional or training programs attended.
Name & Location of School
Dates Attended
Area of Study
Degree/Diploma
Name & Location of School
Dates Attended
Area of Study
Degree/Diploma
Name & Location of School
Dates Attended
Area of Study
Degree/Diploma
EMPLOYER
Please list your last three places of employment, dates of employment and position held.
Name of Employer
Position
Dates of Employment
Name of Employer
Position
Dates of Employment
Name of Employer
Position
Dates of Employment
Briefly explain the type/nature of business in which you are currently, or most recently, employed:
Briefly explain your job responsibilities:
What do you consider to be your most significant career or personal achievement and/or responsibility?
What are your career aspirations? How does leadership play a role?
COMMUNITY INVOLVEMENT
Do you have a current volunteer role with the City of Kettering? If yes, is it a leadership position, and what type?
Briefly describe your volunteer/leadership responsibilities:
Please list any other organizations in which you are currently involved (e.g., other community, civic, professional, business, religious or social organizations, athletics, etc.)
Organization
Dates of Membership
Leadership Position Held
Organization
Dates of Membership
Leadership Position Held
Organization
Dates of Membership
Leadership Position Held
GENERAL
The Kettering Leadership Academy will discuss many community issues. What community issues would you bring to the table for discussion?
The selection committee receives many applications. Why should you be selected for this Academy?
What do you consider the City of Kettering's most serious problem and what do you think should be done about it?
What do you hope to gain from the Kettering Leadership Academy experience? (List three expectations in order of importance to you.)
REFERENCES
Please list below the three persons who may be contacted as a reference for your application. Please choose individuals who are familiar with your leadership / volunteer interests and activities.
Name
First Last
Title
Business
Phone
Name
First Last
Title
Business
Phone
Name
First Last
Title
Business
Phone
FINANCIAL & PARTICIPATION REQUIREMENTS
Participants are expected to meet the financial requirements, as well as participation requirements.
The cost of this Academy is $600.00. Do you have a sponsor?
- Yes
- No
If yes, please provide name and telephone number:
If no, will you be seeking scholarship assistance toward the tuition fee?
- Yes
- No
(limited scholarship money is available)
Participants are expected to attend all sessions (two-day opening retreat and seven full-day classes once a month). Those missing more than two sessions will be denied graduation and asked to withdraw from the program. Will you be able to fulfill the required time commitment?
- Yes
- No
REQUIREMENTS FOR APPLICATION PROCESSING
- Please email a current resume to MaryLou.Randolph@ketteringoh.org - All applications must be submitted by July 6, 2018
COMMITTMENT
By checking this box, I understand the time commitment involved upon being selected for The Kettering Leadership Academy. If selected, I am willing to devote the time and energy needed to be a contributing member of the class. I understand that if I fail to meet the obligations of the Academy I will be asked to withdraw from the program and my tuition will not be refunded. I verify that the information provided on this application is true to the best of my knowledge.
- Yes
- No
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Kettering Leadership Academy Application

BACKGROUND INFORMATION

EDUCATION

EMPLOYER

COMMUNITY INVOLVEMENT

GENERAL

REFERENCES

FINANCIAL & PARTICIPATION REQUIREMENTS

REQUIREMENTS FOR APPLICATION PROCESSING

COMMITTMENT