Leadership Jacksonville

Collegiate Leadership Experience Application Form

Please submit completed application by Thursday, March 22, 2012.

Please e-mail a picture (headshot preferable) to meg@leadershipjax.org by March 22, 2012.

During the process of completing this form, should you want to save your form and continue later, please enter your email below and click "Save". A password will be sent to your email to be used in conjunction with your email in order to retrieve saved form data. Please add the email address: website@leadershipjax.org to your contacts or whitelist to ensure you receive the email containing your password.

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Personal Information
First Name
Last Name

Name Called
Gender
Date of Birth

College/University
College Semesters Completed (as of June 2012)
Major

Preferred Mailing Address
City
State
Zip

E-Mail
Phone
Alternate Phone

Recognitions

List awards, honors, or recognitions for academic, school, or community related activities you have received over the last three years (use space below only):

Organizations and Activities

Please list activities or organizations in which you have participated during the last three years:

Work Experience

List any job experience and briefly tell what it involved:

Considering that there are many applicants for this leadership program, what two or three things do you most want us to know about you?

Each of us has different skills, talents and experiences. What do you offer to the class?

Interview Preference

Please check three (3) days you would be available for a 20 minute interview over the phone:

2012 Interview Dates

Thursday, April 5th 4:00 pm - 9:00 pm Yes No	Tuesday, April 10th 4:00 pm - 9:00 pm Yes No
Thursday, April 19th 4:00 pm - 9:00 pm Yes No	Tuesday, April 24th 4:00 pm - 9:00 pm Yes No
Saturday, April 28th 9:00 am - 2:00 pm Yes No

Once your application is complete and accurate, click the submit button to submit your application.

NOTE: The form may take a little while to process after you hit the submit button. Please be patient.