Mississippi Black Leadership Institute
Creating a Legacy of Leadership in Mississippi
2023-2024 Application
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Section 1: Tell Us About Yourself
Name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Home Phone
Mobile Phone
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
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Have you been proposed for membership before?
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Yes
No
If yes, when?
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What is your role in the community?
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Please attach a current resumé and biography.
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Section 2: Community Service
Please list your organizational/political/social affiliations and role you play within each.
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Why would you like to be a part of the Leadership Institute?
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Section 3: Community Transformation Component
All Institute members are required to implement a community program that is designed to: (1) transform their local community (and perhaps the state); and (2) align with the Institute's goals and objectives to bring awareness to current and emerging communal, cultural, economic, political, and social issues affecting people of color and strategize to provide solutions. Please answer the following questions regarding your community transformation plan, keeping in mind it may change.
Describe Your Project
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Goal(s) of your project / program
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Objective(s) of your project / program
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What questions would you like to answer by implementing this project?
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Who are your stakeholders?
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Section 4: Prospective Member Contract
Signature of applicant
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Date
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Month
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Day
Year
Date
In
case
of
an
emergency,
please
contact:
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Telephone
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