Membership Application PLN by xiaopangnv

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									Program Selection

        The Professional Leadership Network encourages local professionals who have a
desire to engage in the community, mentor the community’s youth, develop their
professional networks, and actively engage in the Dan Beard Council to apply for
membership. The Professional Leadership Network Membership Committee will select
members based on the information and references provided.

Contact Information
Required
Full Name:
Business Phone Number:
Mobile Phone Number:
Preferred E-mail Address:
Company or Organization name:
Title:
Business Address:

Optional
Home Address:
Evening Phone Number:
Personal E-mail Address:

What is the nature of the business/organization?

How long have you been with the business/organization?

Please provide the name and contact information of immediate supervisor:

Year(s) lived/worked in Greater Cincinnati region:

Education
College:
Degree and Major:
Year of Graduation:

Graduate Degree Institution(s):
Type of Degree:
Year of Graduation:



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Questions
Please list your participation in other organizations. Include a brief description of your
role and your dates of involvement:




What do you hope to gain personally and professionally through your participation in the
Professional Leadership Network (150 words or less)?




What is the most significant impact you are hoping to have on your community and the
future leaders of tomorrow (150 words or less)?




What specific strengths and qualities would you bring to the Professional Leadership
network (150 words or less)?




Other Awards and Achievements
Please list any other awards of achievements:




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References
Please provide the contact information for two references. The references provided will
be contacted directly by the membership committee to assist in the application process.

Name:
Organization/Title:
Years known:
Connection with Candidate:
Phone:
Email:

Name:
Organization/Title:
Years known:
Connection with Candidate:
Phone:
Email:


Applicant’s Signature: _____________________________ Date: _______________




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