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Application, Leadership Gulf Coast - MISSISSIPPI GULF COAST

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Application, Leadership Gulf Coast - MISSISSIPPI GULF COAST Powered By Docstoc
					                                      LEADERSHIP
   CONFIDENTIAL                       GULF COAST            APPLICATION
       CONFIDENTIAL APPLICATION FOR APPOINTMENT
Instructions
Type or print in black ink. Complete each section fully. Limit answers to the space
available. Application must be signed by both applicant and employer/sponsor and
returned to LEADERSHIP GULF COAST, 11975E Seaway Road, Gulfport, MS 39503
by close of business May 22, 2010. Application must contain a recent photograph.

Selection Criteria
Participation in LEADERSHIP GULF COAST is open to persons living or working in
Harrison County. A maximum of thirty-seven individuals will be appointed to participate
in the program. Since the number of appointments to LEADERSHIP GULF COAST
is limited, and the amount of applicants is substantial, applicants who are not
selected are encouraged to reapply in subsequent years.

Participants will be chosen by the LEADERSHIP GULF COAST Selection Committee
based upon the information completed on this application. The Committee will be
seeking representation from a cross-section of the community. Participants will be
active in business, education, the arts, religion, government, community-based
organizations, ethnic and minority groups and will reflect the diversity of the community.

Applicants must have the full support of the organization or corporation they represent.

Attendance at all programs listed on the current program calendar is mandatory. Those
who fail to attend may be asked to withdraw, with no refund of tuition.




      11975E Seaway Road      GULFPORT, MS 39503                   228.604.0014
        MISSISSIPPI GULF COAST CHAMBER OF COMMERCE

                                                       LEADERSHIP
        CONFIDENTIAL                                   GULF COAST                    APPLICATION
I. PERSONAL DATA                                                                                  Date

   Name
                               Last                                          First                              Middle

   First Name or Nickname Preferred for Name Tag
   Age               M       F            Place of Birth                                           Race
   Home Address
                             Number                        Street                          City                     Zip Code

   Business Address                                                                    Keesler AFB                  39534
                                 Number                    Street                          City                     Zip Code

   Home Phone                                                       Business Phone
   Fax Number                                                       E-mail Address
   Length of Residence in Gulf Coast Area
   If Married, Spouse Name
   Number of Children                        Names and Ages
   Have you applied to Leadership Gulf Coast before? Yes                   No    If Yes, how many times?
   Hobbies

II. EDUCATION
   (Begin with high school, college(s), advanced degrees and/or specialized training.)
   A.    Name and Location of School                       Dates (from-to)              Degree                 Major




   B.    Special Awards for Academic Performance


   C.    Extracurricular Activities: (Leadership positions held, special honors and awards received during school years.)




                                                                                                           2
III. EMPLOYMENT
   Present Employer          Department of the Air Force               Service Date
   Type of Organization        Government
   Title or Responsibility                                                                       Since

   A.   Briefly describe your responsibilities in your employment:
         Oversees curriculum development for courses supporting over 1,400 faculty and staff members of the




   B.   List previous employment in reverse order: (Include active military duty.)
                       Employer                                    Title/Responsibility                  From                 To




   C.




   D.   Business/Professional Affiliations (if any):
        (Not including civic organizations, public office or political activities)
                        Name or Group                          Positions Held or Assignments              Period of Affiliation

                                                                                                  to

                                                                                                  to

                                                                                                  to


IV. COMMUNITY INVOLVEMENT
   A.   Include community, civic, religious, political, government, social, athletic, or other activities. Do not include
        business/professional activities. Include major role in the organization at this time:
        Organization
        Assignment/Position
        Describe Responsibilities




        Organization
        Assignment/Position
        Describe Responsibilities




                                                                                                         3
IV. COMMUNITY INVOLVEMENT continued

        Organization
        Assignment/Position
        Describe Responsibilities




   B.   If you have additional significant community, civic, religious, political, government, social, athletic or other areas
        of active involvement, please list below:




   C.   What do you consider your most important accomplishment in one of the above organizations? Why?




   D.   How much time each month do you commit to volunteer work?




   E.   What plans do you have for your future in terms of your career, civic, and community affairs?




                                                                                                        4
V. GENERAL INFORMATON
  One of the goals of LEADERSHIP GULF COAST is to build a network of community leaders who can enhance their
  problem-solving and other leadership abilities through shared perspectives and working together.
  A.   What do you feel are the three most significant problems facing the Mississippi Gulf Coast area today?




       What do you feel needs to be done about one of these issues?




  B.   What are the three most notable opportunities the Gulf Coast area has to offer?




       What do you feel needs to be done to develop one of these opportunities?




  C.   What specific skills/knowledge do you hope to gain from your participation in LEADERSHIP GULF COAST?




                                                                                                 5
VI. COMMITMENT
   To graduate from LEADERSHIP GULF COAST, a participant is expected to attend all
   sessions. Opening and Closing retreat are mandatory.

   Get-Acquainted Breakfast                                                                   August 20, 2010

   Orientation Retreat a two-day, out-of-town overnight session                 Sept 30 & October 1, 2010

   One Full Weekday Each Month                                                   October through April
   October 13, 2010         November 17, 2010                    December 8, 2010 January 12, 2011
   February 9, 2011         March 16, 2011                       April 13, 2011

   Closing Retreat a two-day, out-of-town overnight session                              May 11 & 12, 2011

   Graduation May 13, 2011

   I understand the purposes of the LEADERSHIP GULF COAST program and if I am selected I will devote
   the time and resources necessary to complete the program. Even though emergencies do arise, any
   participant missing more than one session, for whatever reason, may be asked to withdraw from the
   program with no refund of tuition. I understand the above commitment and agree to be bound by them in
   signing this application.



                                Applicant Signature                                               Date


   EMPLOYER COMMITMENT (if applicable)
   This application has the approval of this organization and the applicant has our full support which includes
   the time required to participate in the program.


   Firm


   Signature
                                                                                      Title


  TUITION If accepted into the LEADERSHIP GULF COAST program, you or your employer/sponsor will
  be responsible for the tuition fee which covers all program costs. (Costs include opening retreat room and
  meals, monthly session meals, closing retreat and graduation.)
  APPLICATIONS SHOULD BE MAILED TO:                LEADERSHIP GULF COAST
                                                   11975E SEAWAY ROAD
                                                   GULFPORT, MS 39503

                              OR FAXED TO:            (228) 604.0105 ATTENTION: LGC APPLICATION

                  OR HAND DELIVERED TO:               MS GULF COAST CHAMBER OF COMMERCE
                                                      11975E SEAWAY ROAD GULFPORT, MS 39503


 APPLICATIONS MUST BE RECEIVED NO LATER THAN MAY 22, 2010

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