Leadership Maryland

ENCORE PROGRAM APPLICATION

Deadline: Monday, September 30, 2024
Important Application Instructions:

Please Read Carefully Before Proceeding
- Save Your Work: At the end of the application form, be sure to click the SAVE button often and before you submit to secure your progress. Your application will be saved for 30 days, allowing you to continue your work as long as you use the exact same computer or device. You will be prompted to create a free JotForm account to save your work. We recommend creating this account for the best experience.
- Autofill Caution: Avoid using autofill on this form, as it may cause unintended overwriting of other fields. We recommend manually entering your information to ensure accuracy.
- Review Before Submitting: Before final submission, carefully review all fields to ensure accuracy and completeness. This step is crucial to ensure your application is properly processed. Email info@leadershipmd.org for assistance.
- Application Deadline and Fees: The early-bird application fee for submissions received by 5 p.m. on Sunday, September 15th is $50. The fee is $100 for applications submitted after this deadline. All applications must be submitted by Monday, September 30th, 2024.
Name*

First NameMiddle NameLast NameSuffix
Preferred Name*
Preferred Pronouns
ex. she/her/hers
Primary Email Address for all Leadership Maryland correspondence*
Birth Date mm/dd/yyyy*
DEMOGRAPHIC INFORMATION Leadership Maryland seeks to reflect racial, cultural and ethnic diversity in each class. Please indicate the racial category with which you identify: Choose One:*

American Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderWhiteOther
Gender*

MaleFemalePrefer Not to Answer
Are there additional characteristics (ex. gender, ethnicity, cultural, etc.) that define you as an individual that you would like us to consider? If YES, please explain below or simply note 'None'.*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Please select the County in which you LIVE
Personal Email *
Home Phone*
Cell Phone*
Emergency Contact: (Name - Relationship - Phone)*
Please attach a high quality headshot *

Professional head/shoulder photo. .jpg preferred
Cancelof
Employer Name*
Job Title*
Employed Since*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Please select the County in which you WORK
Business Website
www.example.com
Business Email*
Business Phone*
Please indicate your preferred billing address*

Home AddressBusiness AddressOther
Type of Industry (i.e. engineering, law, education, non-profit, utility, consulting)*
Session Topics to Choose From as an Applicant

Below is a list of potential topics for next year's program. Please select your top 7 topics of interest. Once you have selected you will see the list of topics you have chosen. Drag each topic in the order of preference with the top being your most preferred. All applicants will complete the same exercise, and the top 5 topics chosen by all participants will be the focus for the coming year. Those selected for the class will determine the direction we take with the five topics for the year.
ESSAY QUESTIONS
Reflect on your experience in the Executive Program.*

Minimum word count 1000/2000
What have you done since your class year to effect positive change in the state?*

Minimum word count 1000/2000
If selected, what do you expect to gain from the Encore Program experience?*

Minimum word count 1000/2000
Tuition

If selected, you will be invoiced for tuition, which covers all program expenses, except your overnight accommodations and personal transportation costs getting to and from the program location.

Tuition is $4750, when paid-in-full by check or $5000 when paid-in-full by credit card by January 15, 2025 (postmarked). If paid after January 15, 2025 tuition is $5000 if paying by check and $5200 if paying by credit card. Late payment must be paid-in-full by check or Visa or MasterCard by February 15, 2025 (postmarked). A payment plan may be arranged; however, the higher tuition amount of $5000 will apply.

Note that a portion of your tuition, specifically $500, will be allocated to the Emerging Leader Scholarship Fund. This fund plays a crucial role in our commitment to fostering a diverse and inclusive class. By contributing to this scholarship, we ensure that talented individuals from various backgrounds have the opportunity to join our program, regardless of their financial circumstances.
APPLICATION FEE

The early-bird application fee for submissions received by 5 p.m. on Sunday, September 15th is $50. The fee is $100 for applications submitted after this deadline. The fee is non-refundable. You may pay by VISA or MasterCard (no other cards accepted) or by check made payable to Leadership Maryland, PO Box 2442, Easton, MD 21601. Please indicate your payment method. When you click SUBMIT at the end of this application, if selected, your credit card will be charged for the Application Fee. If you opt to pay by check, please mail your check to Leadership Maryland, PO Box 2442, Easton, MD 21601. NOTE: YOUR APPLICATION IS NOT COMPLETE UNTIL THE APPLICATION FEE IS RECEIVED.
How would you like to make payment?*

Credit CardCheck

My Products*

Encore Program Application FeeVisa or Mastercard only. Thank you!

$50.00

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

Check*

Check $50
Final Check List

The deadline is MONDAY, SEPTEMBER 30, 2024. Late or incomplete applications will not be considered.

Be sure you have:
1. Attached a professional color photo
2. Completed your three essay questions
3. Checked your Application Fee payment method
4. SAVE your application
You will receive an email confirmation that your application has been received, as well as a copy of your application. You will also receive a separate email with a receipt for your application fee payment.
I acknowledge and accept the associated time commitment and financial obligation by choosing YES (in lieu of a signature).*

YES
Should be Empty:

ENCORE PROGRAM APPLICATION

Session Topics to Choose From as an Applicant

ESSAY QUESTIONS

Tuition

APPLICATION FEE