Leadership Maryland

CLASS OF 2024 APPLICATION - Deadline: Tuesday, October 31, 2023

Note: Be sure to hit the SAVE button at the end of the form to save your work. Your application will save for 30 days as long as you use the exact same computer or device.

Name*

First NameMiddle NameLast NameSuffix

Preferred Name*

Primary Email Address for all Leadership Maryland correspondence*

example@example.com

Years in MD*

Gender*

Birth Date mm/dd/yyyy*

Employer Name*

Employed Since*

Job Title*

# of Employees You Supervise*

Business Address (Street -City-State-Zip)*

Business Phone*

Fax

Business E-mail*

Business Website

County in which you WORK*

County in which you LIVE*

Briefly Describe Your Company/Organization (limit 135 characters)*

Briefly Describe Your Responsibilities (limit 135 characters)*

Type of Industry (i.e. engineering, law, education, non-profit, utility, consulting)*

HOME INFORMATION Home Address: Street - City - State - Zip*

Home Phone*

Cell Phone*

Personal Email*

Emergency Contact: (Name - Relationship - Phone)*

Please indicate your preferred billing address:*

BusinessHomeOther

DEMOGRAPHIC INFORMATION Leadership Maryland seeks to reflect racial, cultural and ethnic diversity in each class. Please indicate the racial/ethnic category (ies) with which you identify: Choose One:*

Other - Note Below:

Are there other characteristics that define you as an individual that you would like for us to consider. If YES, please explain below, or note "None" .*

PREVIOUS LEADERSHIP PROGRAM EXPERIENCE If you are a graduate of a county, regional, or state leadership program, list program(s) and the year completed below. Do NOT list work-related/military leadership programs. *

PROFESSIONAL HISTORY - (do not list current employer; enter "None" if applicable)

Employer - Title - From/To Date*

What do you consider your highest responsibility or career achievement thus far? (limit 100 characters)*

0/100

EDUCATION - Begin with high school. Include college(s), business or trade schools, and specialized training. School City & State From-To Degree/ Major*

School City & State From-To Degree/Major*

School City & State From-To Degree/Major

List extracurricular activities in college. If none, please enter "none." (limit 55 characters)*

VOLUNTEER ACTIVITIES The Selection Committee places great emphasis on the time you commit to volunteer activities. In order of importance to you, list up to 5 volunteer community, civic, professional, business, social, athletic, religious, or other organizations in which you have been or are currently active in, and state if you held or currently hold a leadership position. (limit 75 characters per line) Organization From-To Leadership Position Held

Organization From-To Leadership Position Held

What have you accomplished in these organizations that you think is important? (limit 255 characters)

0/255

If you have NOT been active in your local community, please describe the factors that kept you from being involved. Has anything changed that will enable you to participate more fully in your community? If so, please explain. (limit 150 characters)

0/150

SPECIAL AWARDS AND HONORS (limit 75 characters per line)

Award/Honor Presented by Year

List your current hobbies and interests outside of your job. (limit 45 characters)

GENERAL INFORMATION - How did you learn about Leadership Maryland?

Other - Note Below:

If selected, what do you hope to gain from your Leadership Maryland experience? (limit 115 characters)*

0/115

How would you use your Leadership Maryland experience for the long-term benefit of Maryland? (limit 115 characters)*

0/115

PERSONAL STATEMENTS - The Selection Committee places great emphasis on your thoroughness in answering this question. There are no wrong answers. In your opinion, what are the TWO most pressing issues/problems facing Maryland today? Explain why and list any recommendations you may have for solving these issues. (limit 2,000 characters)*

0/2000

Application FeeThe application fee is $250. 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.

How would you like to make payment?

Credit cardCheck

Credit Card Payment*

Visa or MasterCard$250.00

Leadership Maryland application fee. Thank you!

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:*

Personal Check $250.00

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 $8,400, when paid-in-full by check or $8,750 when paid-in-full by credit card by March 1, 2024 (postmarked). If paid after March 1, 2024 tuition is $8,750 if paying by check and $9100 if playing by credit card. Late payment must be paid-in-full by check or Visa or MasterCard by April 1, 2024 (postmarked). A payment plan may be arranged; however, the higher tuition amount of $8,750 will apply. Limited financial aid is available. To apply, request a Financial Aid Request Form by emailing info@leadershipmd.org. The form must be completed, signed, scanned, and attached to this application. If applying for financial aid, proof of income is required to be submitted with the Financial Aid Request form. You may scan and attach either a W-2, a K-1 from your company or Schedule C-Form 1040, if self-employed. Additional information may be requested. Awards are based on the applicant's compelling statement of need, the number of requests received, and the amount of available funds. Applicants may request up to $5,000. However, requesting aid does not guarantee you will receive all or any of the amount requested.

Are you requesting financial aid?*

YesNo

If yes, How much ? (Max. $5,000)*

If yes, please scan and ATTACH your completed Financial Aid Request form.*

Select File

If yes, please scan and ATTACH either a W-2 OR a K-1 from your company OR a Schedule C from Form 1040 as proof of income.*

Select File

REFERENCES: Please list TWO references below. Attach a letter of recommendation for ONE of these two references.*

REFERENCE #1 - Name Title Company*

Phone and Email*

REFERENCE #2 - Name Title Company*

Phone and Email*

Below please ATTACH one Letter of Recommendation from one of the above references.*

Select File

Authorizing Official StatementYou are required to include the following statement and contract information signed by your CEO/Supervisor OR indicate below that you are your own supervisor. Statement: "This candidate has my full support to participate in Leadership Maryland. I am aware of the time commitment and financial obligation involved." The letter should include: (1) Supervisor Name (2) Title (3) Company (4) Phone (5) Email (6) Signature and (7) Date.

I acknowledge that I am my own supervisor.*

YesNo

If not, please ATTACH a signed "Authorizing Official Statement" from your supervisor.

Select File

Please attach a professional color photo (head/shoulder shot in jpg. format)*

Select File

I acknowledge and agree to these commitments by choosing YES below (in lieu of signature).*

Yes

Application Instructions:

The deadline is TUESDAY, OCTOBER 31, 2023. Late or incomplete applications will not be considered. 1) Be sure you have: a. Checked your Application Fee payment method; b. attached Financial Aid Request Form and proof of income, if requesting aid; c. attached one Letter of Recommendation; d. attached signed Authorizing Official Statement, if applicable; and e. attached a professional color photo. 2) When you click SUBMIT at the end of this application, if selected, your credit card will be charged the $250 Application Fee. If you opt to pay by check, please mail your personal check to Leadership Maryland, PO Box 2442, Easton, MD 21601. NOTE: YOUR APPLICATION IS NOT COMPLETE UNTIL THE APPLICATION FEE IS RECEIVED. 3) 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. 4) Please note, incomplete or late applications will not be considered.

Leadership Maryland PO Box 2442 Easton, MD 21601 (410) 841-2101

Questions: info@leadershipmd.org