Adult Application

Application Form
Name of Applicant*
Prefix First Last
Primary Address*
Street Address Address Line 2 City State ZIP
Primary Phone Number
Primary Email*
Enter Email Confirm Email

Please provide an email that allows attachments, forms, and group emails.
Have you applied for Leadership Clarksville before?*

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Education
Formal Education*
Begin with High School, then College (s), business or trade schools and / or specialized training to include dates of attendance, degrees conferred, and majors.
Employment Information
Job Title*
Place of Present Employment*
Work Address*
Street Address Address Line 2 City State ZIP
Date Began Present Employer*
Previous Employment*
Please list previous employers for five years with dates of employment and job titles or responsibilities
What is your highest skill or career achievement so far?*

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Organizations and Activities
Memberships*
Organization Membership Dates Positions Held

Please list, in order of personal importance, up to five community, civic, professional, business, religious, social, athletic, and other organizations of which you are or have been a member.
What have you accomplished in these that you think important?*
How much time each month do you commit to civic activities?*
Are you as active in civic activities as you would like to be?*
If not, what have been the major barriers to more involvement?*
What has changed to allow you more time for civic involvement?*

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General
How long have you lived in Montgomery County?*
If not a native, why did you move to Montgomery County?*
How would you describe your knowledge of community affairs?*
- Poor
- Fair
- Good
- Excellent
How would you describe your activity in community affairs?*
- Poor
- Fair
- Good
- Excellent
Would you be willing to serve a committee requiring two evenings a month?*
Does your job afford you the ability to attend meetings during the day?*
If you were considered an expert in a field, what would it be?*

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Opportunity
What do you hope to gain from your Leadership Clarksville experience?*
In your judgment, what are the three most pressing concerns or needs facing Clarksville/Montgomery County today?*
Explain why and any recommendations for resolving these issues.
Your tuition will include transportation, single occupancy high end lodging, and meal expense of the opening retreat. Full tuition ($1250) must be paid by August 31 prior to the start of the program year, either personally or by employer. Tuition is non-refundable if withdrawn/removed from the course. Please type here to indicate understanding and acceptance.*
We must ask that class participants commit to ALL Leadership Clarksville program activities, generally including the initial two day orientation retreat in September then one day per month from October through May. Are you and your employer willing to make such a commitment?*

Absenteeism will result in removal from the course and forfeiture of tuition.
I understand the purposes of the Leadership Clarksville program and , if selected, will devote the time required for program completion.*

Indicate acceptance by typing full name (First,Middle, Last) and date of signature.
Enclosed is a letter of recommendation by:*
Please include the name, employer, telephone, email, and relationship of at least one Leadership Clarksville graduate submitting a reference letter on your behalf. Attach digital copy of the letter immediately below-
Letter of Recommendation*
Max. file size: 100 MB.
Attach one page letter of recommendation digitally from recommender.
Additional References*
Please submit the name of two additional references and contact information.
IMPORTANT!!!
Full Face Photograph*
Max. file size: 100 MB.
A full face photograph must be uploaded here with the application before consideration of selection is given.
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Email
This field is for validation purposes and should be left unchanged.

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Class of 2023 Application Deadline:

May 31, 2023

Step 1 of 5

Application Form

Education

Employment Information

Organizations and Activities

General

Opportunity

IMPORTANT!!!

Lend Your Support

Organization	Membership Dates	Positions Held