Leadership Putnam Application

Name

First NameMiddle NameLast Name

E-mail

example@example.com

Who recruited you or encouraged you to apply to Leadership Putnam?

Complete and return this application (address shown below), along with a $10 non-refundable application fee by June 15, 2023, for consideration for the class of 2024. Please fill out completely – the application form will be used in the selection process. Incomplete (except where optional) or late applications will not be considered.

Angie Wells

Leadership Putnam

1 West First Street

Cookeville, TN 38501

931-526-2211

awells@cookevillechamber.com

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

What is your gender?

Leadership Putnam strives for diversity among its participants with regard to gender,race, age, etc. Completion of the following information is optional and requested only to help us achieve the diversity we seek.

Age?

What is your race?

Employment Information:

Business NameYour Title/Position

Work Address:

Business Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone Number

Please enter a valid phone number.

Years Employed?

Job Responsibilities:

Organization/Activities/Volunteerism: please list in order of importance to you, up to five community, civic, professional, business, religious, social, athletic, or other organizations of which you are or have been a member.

What have you accomplished as a result of these activities that you feel has benefited the community or its residents?

How many hours do you devote to these activities each month?

Have you been as involved in the community as you would like to be? If not, what are some of the barriers to your involvement?

Are you a registered and active voter?

What do you hope to gain from your Leadership Putnam experience that will benefit our community?

Please identify a particular issue, challenge, or problem you feel is critical in Putnam County. Briefly explain your concern, impossible involvement in finding a solution to this issue:

Commitment/Participation:

To graduate from Leadership Putnam only one excused absent from any program day is possible. Attendance at the opening retreat is mandatory. Typical schedule is as follows:

Opening Retreat: August 10 and 11th (Thursday night dinner and Friday morning teambuilding, etc. This is not overnight!)
Program Days: September through May. (This is a full 8-hour day, usually the first Thursday of each month. There will be no program day during December.)
Graduation: tentatively, May 9, 2024.
Projects: Time/level of commitment involved will be determined by individual project groups.

Are you and your employer willing to make this commitment?

* Absolute absenteeism will result in the participant being dropped from the program. If you are unable to make this time commitment, it is not in your best interest to apply at this time.

How long have you lived in Putnam County?

Do you realistically expect to still be living or working in Putnam County in the next five years?

Please list up to 3 references including their name/company/address/contact phone number/email:

By my signature appearing below, I agree to mail my $10 application fee. I further agree to all terms as listed by Leadership Putnam. I further understand that this application does not secure my spot in this program and members will be chosen on a case by case basis of availability. I will be notified of my acceptance at a later date. Upon acceptance, a tuition fee of $750 will be due and payable no later than August 1st and is non-refundable. Tuition May be paid by a sponsor, such as an employer. Partial assistance is available on a very limited basis, and is based on unique circumstances, contact Leadership Putnam for details. As a Leadership Putnam alum, you will be expected to have an ongoing commitment to the growth in continuity of the program as well as our community.

Signature

Clear

Attach a headshot for our use here:

Please give us a short bio of yourself (3-5 sentences)

Application Form