Leadership Louisville Class of 2014 Application

Name and Title

Courtesy Title*

First Name*

Middle Initial

Last Name*

Suffix

Preferred First Name (for nametag)*

Current Employment

Job Title*

Employer*

Business Address*

Business City*

Business State*

Business Zip*

Business Phone*

(###)###-####

Business Email*

Personal Contact Information

Home Phone*

(###)###-####

Cell Phone*

(###)###-####

Home Email

Preferred Email*

Spouse's Name

Home Address*

Home City*

Home State*

Home Zip*

Other Information

Birth Date*

mm/dd/yyyy

Gender*

Race*

Occupation Category *

Please select the occupational category that best describes your company/organization.

If not from Louisville, enter Hometown City

If not from Kentucky, enter Hometown State or Country

Who is ultimately responsible for covering your tuition costs?*

My employer will either pay or reimburse me for the entire tuition.
My employer will either pay or reimburse me for a portion of the tuition.
An organization other than my employer will either pay or reimburse me for all or a portion of the tuition.
I am personally responsible for the entire tuition.

Scholarship

If you are requesting financial assistance to participate in this program, please complete the following questions. While we are able to offer financial assistance, the Leadership Louisville Center does not provide full scholarships. To receive consideration, questions must be answered completely and accurately.

Are you requesting a scholarship?

Yes
No

Please indicate the total amount you requesting. We do not grant full scholarships, but we would like to enable your participation.

Why are you requesting a scholarship?

Will you be able to participate in this program if your scholarship request is not granted?

Yes
No

Employment History

Please list your last three employers, beginning with the most recent.

Click the "+" sign to add employers.

Employers*

Employer	Title	From Year (yyyy)	To Year (yyyy)

Education

Please list any degrees or certifications you have received, beginning with the most recent.

Click the "+" sign to add more organizations.

Education

Institution	Degree	From Year (yyyy)	To Year (yyyy)

For From Year and To Year, please enter ONLY 4-digit year (not month, day, year)

Community Service

Please list your community service activities, beginning with the most recent.

Click the "+" sign to add more organizations

Community Service

Organization	Role	From Year (yyyy)	To Year (yyyy)

Interview

Feel free to respond to the Interview questions as thoroughly as you like, but 200 words or less per question is preferred.

The mission of the Leadership Louisville Center is to grow and connect a diverse network of leaders who serve as catalysts for a world-class community. Please describe 1-3 things you have accomplished toward this mission.*

What does Louisville need to become a world-class community?*

What life experiences and perspectives do you bring to the class that would make you a unique participant?*

What have you experienced in other Leadership Louisville Center programs, or what do you know about the work of the Leadership Louisville Center, that makes you excited to be part of the Leadership Louisville program?*

Recommendations

Please provide the names of the three individuals who will be submitting recommendations on your behalf. Instruct them to use the online recommendation form, at www.leadershiplouisville.org/leadership-louisville/leadership-louisville-2014-recommendation-form/.

Name	Title	Company

Name	Title	Company

Name	Title	Company

Talent and Board Matching

National, regional and local leaders often look to the Leadership Louisville Center as a resource for identifying board members, community volunteers and subject matter experts. Please indicate your areas of expertise and interests as well as your board service experience so we may include you in such talent searches.

Areas of Expertise

Please check all that apply.

Areas of Interest

Please check all that apply.

Board Service information Past and present (separate names of organizations with a comma)

How did you learn about this program?

How did you hear about this program?*

Brochure/Marketing materials
Community Event
Email from Leadership Louisville Center
Leadership Louisville Center event or program
Leadership Louisville Center website
News story or ad in media (TV/newspaper/magazine)
Online or social media (Internet, Facebook, Twitter or LinkedIn)
Referred by family friend or program graduate
Suggested by employer/colleague

If not listed, please tell us how you heard about this program.

If referred by someone, who can we thank for referring you?

Photo Upload

Please upload a print-quality digital photograph of yourself (with JPG or TIFF file extension) at least 4 in. x 5 in. size, if possible. You may upload it using the form below.

Though you may proceed with this application without uploading a digital photo at this time, your application will not be processed until we have received your photo. Please contact Peggy Clements at (502) 561-5228 or pclements@leadershiplouisville.org if you need assistance with this process.

Photo File

Participation in the Leadership Louisville program requires a commitment from you to attend the mandatory overnight retreat (8:00 a.m. August 22 until 5 p.m. August 23) and each of the monthly sessions, which run from 8:00 a.m. until 5:00 p.m., in their entirety (dates listed on the Leadership Louisville program page, http://www.leadershiplouisville.org/leadership-louisville/#calendar). This level of commitment will require support from your employer, family and other obligations. The program is only successful when all participants are committed to attend. Are you prepared for the time commitment required to be a full participant in the Leadership Louisville program? *

Yes
No

IMPORTANT - PLEASE READ!

After clicking the Submit button, it may take a few moments to process - especially if you uploaded a large photo. If your application submitted successfully, you will see a confirmation page and receive an email within five minutes.

If instead, you are redirected to the top of the form, just scroll down to fields that may be highlighted in red, indicating errors. If, after correcting errors and resubmitting, you do not see the confirmation page, please do not close your browser. Print the page and contact us as soon as possible at (502) 561-0458.

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