PLI Application Form

Southeast Kentucky Chamber's Patton Leadership Institute

2025-2026 | Applications Due September 21, 2025
Questions must be answered fully and completely. Applications must be submitted by the applicant, approved by the employer/sponsor, and received by the Chamber no later than the deadline.
Name

First/PreferredLast
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone

Area CodePhone Number
Email
County of Residence
County of Employment
Birth Date

MonthDayYear
Date
Age as of October 1
Race/Ethnicity

White/CaucasianBlack/AfricanHispanicAsianOther
Gender

FemaleMaleOther
How man years have you lived in Eastern Kentucky?
Employer & Education
Employer
Title
Duties

0/50
Years with Employer

1 Year or Less1-3 Years3-5 Years5 Years or More
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Highest educational attainment

High SchoolAssociatesBachelorsMastersDoctoral/Professional
Major
Short Answer
What do you expect to gain by participating in Patton Leadership Institute?

0/200
What are the three most important challenges our region is facing? Explain why.

0/500
Provide a brief bio

0/150
Attendance Commitment

I understand the purposes of Patton Leadership Institute and if I am selected, I will devote the time and resources necessary to complete the program. The Opening Retreat is mandatory (no exceptions will be made). Though emergencies do arise, any participant missing more than two of the regular sessions, may be asked to withdraw from the program and no portion of the tuition shall be refunded. Arriving more than one hour late or leaving more than one hour early will be considered an absence. I understand the above commitments as well as have approval,support, and commitment from my employer including the time required to participate in the program and agree to be bound by them by submitting this application.
My schedule, both work & personal, will allow me to make this commitment.

NoYes
I understand that sessions are typically held from 8 am to 5 pm, and are in a different county each month, and that no more than two absences are allowed and that leaving early or arriving late counts as an absence.

NoYes
Recommendations & References

Two letters of recommendation must be submitted on your behalf. It is the responsibility of the applicant to contact the reference and request a recommendation be submitted. Such letters should describe the applicant’s potential as a future community leader and how his/her leadership will benefit the community. Letters must be received by the application deadline, and should be sent to: info@sekchamber.com.
Recommendations & References

Two letters of recommendation must be submitted on your behalf. It is the responsibility of the applicant to contact the reference and request a recommendation be submitted. Such letters should describe the applicant’s potential as a future community leader and how his/her leadership will benefit the community. Letters must be received by the application deadline, and should be sent to: info@sekchamber.com.

References

	Full Name	Title	Business	Number	Email
1
2

If accepted into PLI, you will be billed for the full cost of tuition, which covers all program costs, excluding transportation to and from session sites. We encourage participants to ask their employers to sponsor their tuition fees. Tuition must be paid in full before October 1, and is non-refundable.

If you need financial assistance, please call to request a scholarship application. This will not be a part of the selection process; however, the completed form must be submitted by the application deadline. A request for scholarship does not ensure you will receive a scholarship.

All applications are subject to confidential evaluation. A geographical mix of residents is a consideration in selection of the class. If you are not selected to participate in this year's class your application may be retained for consideration in later years.

Thank you for your interest in Patton Leadership Institute!
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Southeast Kentucky Chamber's Patton Leadership Institute

Employer & Education

Short Answer

Attendance Commitment

Recommendations & References

Recommendations & References