Leadership Cobb Class of 2011-2012 Application
*In case of technical difficulties, may we suggest answering and saving your
responses in Microsoft Word. Then copy and paste your answers in the fields below.
Before filling out the application, please read over the documents provided in
the links below.
I. BASIC INFORMATION |
| *Last Name: |
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| *First Name: |
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| Middle Name: |
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| *Name Called: |
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| *Title/Position: |
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| *Present Employer: |
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| *Business Mailing Address: |
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| *Business Mailing City: |
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| *Business Mailing Zip Code: |
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| *Business Mailing County: |
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| *Business Phone: |
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| *Mobile Phone: |
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| *E-Mail Address: |
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| *Home Address: |
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| *Home City: |
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| *Home Zip: |
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| *Home County: |
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| *Date of Birth: |
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| *Sex: |
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| *Race: |
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| *How long have you lived in Cobb County? |
Years |
| Since last move here, if different: |
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| *How many times have you applied for Leadeship Cobb |
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*Why do you want to be a member of the 2011-2012 Leadership Cobb
class?
(limit response to 100 words or fewer)
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II. COMMUNITY & CIVIC INVOLVEMENT |
| Include civic, religious, political, government,
social, athletic or other activities. Indicate major role in the
organization(s) at this time. Do not include
business/professional activities. |
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| 1. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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| 2. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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| 3. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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| 4. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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If you have additional significant community, civic, religious,
government, political, social, athletic or other areas of active
involvement, please list below: (limit response to 100
words or fewer)
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Are there any important contributions, achievements or
recognitions in any of the above organizations that you
consider significant, and what was your role in their
accomplishment? Please list any community awards you
have received, along with granting organization and date. (limit
response to 100 words or fewer)
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III. PRESENT EMPLOYMENT |
*Which of the following best describes your present
position (choose only one):
List Other here:
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| If you are presently employed or self-employed,
please complete the remaining parts of this section. (If not
employed, please go to the Employment Record Section) |
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| Present Title or Position: |
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Briefly describe your responsibilities in your position: (limit
response to 50 words or fewer)
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Please indicate how your present position relates to the Cobb
community: (limit response to 50 words or fewer)
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What do you consider your most significant contribution or
achievement related to your position so far? (limit response to
50 words or fewer)
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Employment Record (Current and past) List
most recent position first.
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IV. BUSINESS/PROFESSIONAL AFFILIATION AND
INVOLVEMENT |
| 1. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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| 2. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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| 3. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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| 4. Organization: |
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| Assignment/Position: |
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From:
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To:
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Describe Personal Responsibilities (limit response to 25 words
or fewer):
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If you have any additional significant business/professional
affiliations, please list below: (limit response to 50 words or
fewer)
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Are there any important contributions or achievements in any of
the above organizations, which you consider significant, and
what was your role in the accomplishment? Please list any
business/professional awards you have received, along with
granting organization and date. (limit response to 50 words or
fewer)
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V. BACKGROUND INFORMATION |
| Education Background |
| High School: |
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| College: |
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| Degree(s): |
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| Graduate School: |
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| Degree(s): |
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Other Training:
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Occupational/Professional Certificates or Licensure:
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Activities, offices, recognitions for special contributions
received during school years: (limit response to 50 words
or fewer)
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DEADLINE: Applications must be
RECEIVED by
Friday, March 25, 2011,
at 4:30 p.m. NO APPLICATIONS WILL BE
ACCEPTED AFTER THIS DEADLINE.
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| Your application will
not be complete without a signed commitment form. Download a copy of
this form by clicking
here. Forms can be returned by
email, mail or in person. |
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