I. BASIC INFORMATION |
| *First Name: |
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| *Middle Name: |
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| *Last Name: |
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*Preferred Name:
This name will be used for all future correspondence, press and materials should you be selected to the 2023-2024 class of Leadership Cobb. |
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| *Business Mailing County: |
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| *Business Phone: |
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| *Mobile Phone: |
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| *Preferred Email Address: |
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| *Home County: |
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| *Date of Birth: |
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| *Gender: |
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| *Race: |
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| *Have you ever served in the U.S. Military? |
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| If yes, please tell us which branch you served in. |
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| *How many times have you applied for Leadeship Cobb? |
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II. 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 Company: |
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| Present Title or Position: |
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Briefly describe your responsibilities in your position and how it relates to the Cobb Community: (limit
response to 100 words or fewer)
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What do you consider your most significant contribution or
achievement related to your position or company so far? (limit response to
50 words or fewer)
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What has been your biggest challenge related to your position so far? (limit response to
50 words or fewer)
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| Past Employment Record
List
most recent position first, excluding your current position.
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III. BUSINESS/PROFESSIONAL AFFILIATION AND
INVOLVEMENT
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Include any business/professional affiliations or involvement outside of current or past employment. (ex: professional associations or development programs)
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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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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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IV. COMMUNITY & CIVIC INVOLVEMENT |
| Include non-profit/community outreach, 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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|
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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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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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Of the community, civic, and voluntary activities listed on this application, which is MOST important to you? Why? Describe your responsibilities, your leadership role(s), and how your efforts have impacted the community. (limit
response to 100 words or fewer)
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V. EDUCATION, RECOGNITION, AWARDS |
| 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, occupational/professional certificates or licensure (100 word limit):
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Awards, activities, offices, recognitions for special contributions: (limit response to 50 words
or fewer)
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V. LEADERSHIP |
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*This section is heavily weighted.
Why do you want to be a member of the 2023-2024 Leadership Cobb
class?
(limit response to 100 words or fewer)
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What do you hope to gain both professionally and personally from your Leadership Cobb experience?
(limit response to 100 words or fewer)
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What do you hope to contribute both professionally and personally to the program and your community?
(limit response to 100 words or fewer)
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What do you think are the three most pressing issues that Cobb County is facing?
(limit response to 100 words or fewer)
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