Name

Address
.
City State & Zip

Home Phone & Business Phone

Business Address


Where do you want mail sent?
Home ..Business
Your exact title and name of firm (as you would want it published)

Your name as you would want it on a name tag

Spouse’s Name

Number of years lived in the Haleyville area
If you have lived in other communities, please list

EDUCATION - SCHOOL DATES ATTENDED DEGREE

EMPLOYMENT - PRESENT EMPLOYER


EMPLOYMENT - JOB DESCRIPTION



Firm

Title
How Long Employed
PREVIOUS EMPLOYMENT

EMPLOYER TITLE FROM/TO
Brief job Description

ORGANIZATIONS AND ACTIVITIES
List community, professional, civic, religious and other organizations that you are
or have been affiliated with and offices held. (Limit to 10 most important to you)





ORGANIZATION DATES OFFICES HELD & ACHIEVEMENTS



In your judgement, what are the three most pressing problems facing the
Haleyville area and recommendations for solutions?



Have you been as active in community activities as you would like to be?
Yes No
If not, what have been the major barriers to your becoming involved



What do you hope to gain from your involvement in Leadership Haleyville?



Do you have the full support of your employer for the time required to participate
effectively in Leadership Haleyville?Yes No
Name of Supervisor

Phone


Will you be willing and able to attend, in addition to scheduled sessions, other public
and civic meetings as required with proper notice?Yes No
Will you be able to attend the Leadership Haleyville sessions as outlined?
Yes No
Would you like to receive additional information concerning the Leadership Scholarship?
Yes No
Will you be applying for a partial scholarship for the Leadership Program?Yes No

Note: Even if a partial scholarship will be applied for, full tuitiution of $125.00 must
accompany this application for consideration.

Date Signature of Applicant