Application – Lead Virginia

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Application

Before you submit the application below, please be sure to have your résumé, issue description and application fee ready.

The deadline to apply for the LEAD VIRGINIA class of 2011 is Jan. 15.

Personal contact information

Title:
First name:
Middle name:
Last name:
Maiden name:
Street address:
Street address:
City:
State:
ZIP code:
Home phone:
Cell phone:
Recommended or
referred by:

Professional contact information

Employer:
Position or title:
Street address:
Suite:
City:
State:
ZIP code:
Phone:
Fax:
E-mail:
Website:
Assistant’s name:
Assistant’s phone:
Assistant’s e-mail:
Briefly describe your company or organization, including the sector (public or private business, government, education, nonprofit or other profession) and type (i.e., banking, utility, marketing, military, higher education, law or community services).

Demographic information

I live in a(n):
I work in a(n):
Age:
Years in Virginia:
Family (spouse, children or significant):
Please describe your race or ethnic background (optional):

Community and leadership education

Have you completed a community leadership program or other leadership education or training? If so, please list the program(s) and year(s) completed and note your volunteer or leadership roles.

Résumé, curriculum vitae or biographical sketch

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Scholarship assistance

Would you like scholarship assistance?
If yes, how much assistance do you need?
Reason for the request:

Issue description

Describe your personal views on the following topic: What are the two most pressing issues or challenges facing Virginia today? Explain why and offer recommendations for approaching and solving these challenges. The suggested length of response is no more than one-half page.
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Signature:

LEAD Virginia | 707 E. Main Street, Suite 1035| Richmond, Virginia, 23219
Phone: (804) 644-LEAD (5323)| Fax: (804) 644-0062
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Last updated: 01/08/2010

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