2022 CORE Program Application - Leadership Montgomery

Personal Information:
Salutation *
First Name *
Middle Initial
Last Name *
Suffix
Nickname/Preferred Name *
Preferred Pronouns *
What other LM programs (if any) have you participanted in?

Emerging Leaders REAL Inclusion Senior Leadership Montgomery
Contact Information:
Mobile Phone *

Area Code Phone Number
Secondary Phone (if applicable)

Area Code Phone Number
Which phone number is provided above?
Which is your preferred phone number? *
Primary Email *
example@example.com
Additional Email (if applicable)
example@example.com
What is your primary address? *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Which address is above?
Provide a secondary address? (if applicable)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Which address is above?
What is your preferred mailing address? *
How many years have you lived in Montgomery County? *
How did you find out about Leadership Montgomery?
Please specify
Personal Contact
Which Social Media Platform?
You are able to save and continue later via the button at the bottom of the application
Demographic Information:
Gender *

Male Female Non-binary/ third gender Prefer to self-describe Prefer not to answer
Birth Date *

Month Day Year
Date
Race/ Ethnicity (optional) Leadership Montgomery seeks to reflect, cultural and ethnic diversity among its participants. Please indicate the racial/ ethnic category(ies) with which you identify.

African American Asian Caucasian Hispanic Middle Eastern Two or More Races Native American
Current Employment (if applicable)
Organization Name
Job Title
Current Employment Status *

Working Full- Time Working Part- Time Semi- Retired Fully- Retired
Professional Affiliation:

(if applicable)
Organization Category
Please select the category that best describes your organization
Organization Industry
Please choose the category that best describes what your organization does.
Employment History:

List TWO previous positions, beginning with the most recent first. Include active military duty, if applicable:
Upload a resume in lieu of answering following employment questions

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Employer
Title/Responsibility
From

Month Day Year
Date
To (leave blank if currently employed)

Month Day Year
Date
Employer
Title/Responsibility
From

Month Day Year
Date
To

Month Day Year
Date
Describe your current company/organization:
Describe your responsibilities at work:
Education:
Check highest level attained
Special Awards/ Honors:
Presented By
Award/Honor
Year
Presented By
Award/Honor
Year
You are able to save and continue later via the button at the bottom of the application
Volunteer Activities and Community Involvement:

Please list, in order of importance to you, the nonprofit, civic, professional, social, religious, athletic or other organizations in which you are or have been involved with. Note. This is an important part of the selection criteria.
Organization
Position Held
Hours per month

0-5 5-10 10-15 15-20 20+
Organization
Position Held
Hours per month

0-5 5-10 10-15 15-20 20+
Organization
Position Held
Hours per month

0-5 5-10 10-15 15-20 20+
Organization
Position Held
Hours per month

0-5 5-10 10-15 15-20 20+
Open Ended Questions:
List top three personal objectives for participating in Senior Leadership Montgomery *
If you have not had time or interest to become actively involved in the community, what has changed that now enables you to seek involvement? (answer only if relevant.)
If accepted, what do you think you can contribute to the class? *
What community issues are you most interested in (select 3 max)?

Transportation Education Housing Aging in Place Volunteerism/ Mentorship
Tuition and Funding

If selected for the Senior Leadership Montgomery program, you will be billed $950, which covers all program costs. If your tuition is being paid by a sponsoring organization, you must personally pay $95 to demonstrate your commitment. Payment plans are available upon request.
Tuition Assistance Form

Tuition assistance is considered separately from your application and has no influence or effect on the Selection Committee's evaluation of your application. All information will remain confidential. **PLEASE NOTE** You will need to download or print the form, then upload the completed form in the appropriate box below along with supporting documents.
Upload Completed Tuition Assistance Form Here

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**Reminder**You will need to download or print the form, then upload the completed form. Cancel of
Supporting Document 1 (i/e 1040/990)

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Cancel of
Supporting Document 2 (i/e 1040/990/other)

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Cancel of
Statement of Commitment

If selected, I agree to secure payment for the entire nonrefundable tuition of $950 by Friday, July 15, 2022 and meet all the attendance requirements as outlined in the application.
Applicant's Signature

Clear
Leadership Montgomery requires certification by submitting an electronic signature. To certify your application, confirm your signature. *

Confirm Signature

To finalize your application, please pay the Senior Leadership Montgomery application fee: *

SLM application fee $ 50.00

$50 for first time applicants.

SLM application fee $ 25.00

$25 for previous SLM applicants.

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please verify that you are human *
Should be Empty:

Personal Information:

Contact Information:

You are able to save and continue later via the button at the bottom of the application

Demographic Information:

Current Employment (if applicable)

Professional Affiliation:

Employment History:

Education:

Special Awards/ Honors:

You are able to save and continue later via the button at the bottom of the application

Volunteer Activities and Community Involvement:

Open Ended Questions:

Tuition and Funding

Tuition Assistance Form

Statement of Commitment