2024 CORE Program Application - Leadership Montgomery

Encore Program Application

This application can be saved and continued later via the button at the bottom of the application. The application is broken into several sections for ease of navigation; be sure to complete all required questions in each section. The final step in the application process is the submission of an application fee of $65 ($25 for repeat applicants).
Applications can be submitted at any time. Applications submitted between May 1 and August 31 may be placed on a waiting list to be considered for the next cohort beginning in September and/or consideration for the following cohort. Please check the option below to indicate if you would like to be considered for the cohort beginning in September.

Please consider my application for the cohort beginning in September

Personal & Contact Information
Salutation*
First Name*
Middle Initial
Last Name*
Suffix
Nickname/Preferred Name
Please indicate how you would prefer to be addressed (i.e., what name you prefer to have on a nametag).
Preferred Pronouns
Please indicate if/how you would like your pronouns to appear on a nametag.
What other LM programs (if any) have you participated in?

Business Leaders Impact CouncilCOREEmerging LeadersREAL InclusionSenior Leadership MontgomeryOther
Mobile Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
What type of number is your secondary phone?
Which is your preferred phone?*
Primary Email*
List the primary email you would like to use for Leadership Montgomery communications.
Additional Email*
Please list a secondary email should we be unable to reach you via your primary email.
Administrative Assistant Email
If you would like an administrative assistant to be copied on all Leadership Montgomery communications, please input that email address here.
What is your primary/preferred address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate your primary/preferred address type.*
Secondary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate your secondary address type.
How many years have you lived in Montgomery County?*
How did you hear about Leadership Montgomery?*
Please specify

Professional Affiliation & Employment History
For most applicants, this is an employer. If you are retired, please indicate your last employer, position, or field with a "retired" as your job title.
Organization*
Job Title*
Organization Category*
Please select the category that best describes your organization
Organization Industry*
Please choose the category that best describes what your organization does.
How will you share you Employment History, Education, & Awards/Recognition*

Upload a PDF resumeEnter manually below
Upload a resume in lieu of answering following questions regarding employment and education

Browse Files

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Employment History, Education, & Awards/Recognition
Employment History

List previous positions, beginning with the most recent first. Include active military duty, if applicable:
Employer
Title/Responsibility
Employer
Title/Responsibility
Employer
Title/Responsibility
Describe your current company/organization:
Describe your responsibilities at work:
If you upload your resume, please insert N/A to continue with application.
Education

Begin with the most recent, and include high school or equivalent, college(s), and any postgraduate studies.
School Name, City & State
Degree Awarded
School Name, City & State
Degree Awarded
School Name, City & State
Degree Awarded
Special Awards/ Honors
Presented By
Award/Honor
Year
Presented By
Award/Honor
Year

Tuition and Funding
Tuition for participants accepted to Leadership Montgomery's Encore program is $950, billable upon acceptance into the program. Participants whose participation is sponsored by an employer or other organization are required to contribute 10% of the tuition ($95) as a demonstration of personal commitment. Payment plans and tuition assistance are available upon request.
Tuition Options (check all that apply)

Bill 90% of tuition to sponsoring organization (specify below) and 10% to applicantBill 100% of tuition to applicantPayment plan requested (LM will follow up with payment plan options)Tuition assistance requested (application below)
Sponsoring Organization

Tuition Assistance
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. Tuition assistance requests must be submitted at the time of application. All information will remain confidential. **PLEASE NOTE** You must download or print the form, then upload the completed form and supporting documents in PDF format using the upload functions below.
Completed Tuition Assistance Form

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**REMINDER** You will need to download or print the form above, then upload the completed form here. Cancelof
Supporting Document 1 (i.e 1040/990)

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Supporting Document 2 (i.e 1040/990/other)

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Statement of Commitment & Application Fee
If selected to participate in the Encore Class of 2025, I agree to secure payment or payment plan contract for the entire nonrefundable tuition of $950 by Monday, July 15th, 2024. I understand that I am required to attend each session and meet the attendance requirements as outlined in the program description, and that missing more than 8 hours could result in dismissal from the program.
Applicant's Signature*

Clear
Leadership Montgomery requires certification by submitting an electronic signature.*

Confirm Signature

To finalize your application, please pay the Encore application fee: *

Encore application fee$65.00

$65 for first-time applicants.

Encore re-application fee $25.00

$25 for previous 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

Save or Submit
You may save and continue your application via the save button below.

NOTE: JotForm deletes unsubmitted applications after 60 days. All required fields (marked with a red asterisk*) must be completed before the application can be submitted.
Should be Empty:

Encore Program Application