Atlanta Regional Commission

Atlanta Regional Commission

Regional Leadership Institute

Application

Name

Last FirstMiddle

Name/Nickname Preferred for name badge ______

○Male ○FemaleRace ______

Home Address______

City State Zip

Telephone

OccupationEmployer

Type of Business/Organization Years of Service

Work Address

City StateZip Telephone

Your Email Address:

Your Job Title & Name of Firm:

Past Employment

EmployerTitleYears of Service

Please list the community organizations with which you have been involved over the past five years
OrganizationPositionService Period

1. Please describe your position and sphere of influence within your organization:

2. What have you accomplished in your work or volunteer efforts, past or present that has effected positive community change in the region?

3. What do you hope to gain from your experience in the REGIONAL LEADERSHIP INSTITUTE?

4. What one or two regional challenges or opportunities do you see as critical to continued regional success?

5. Name two persons the selection committee may contact for additional information about you:

NameOrganizationEmailTelephone

6. How or from whom did you learn about the REGIONAL LEADERSHIP INSTITUTE?

7. Any other comments?

8. Do you have the full support of your employer to be out of the office and fully engaged in the REGIIONAL LEADERSHIP INSTITUTE for the time required?

Commitment Statements

Attendance- The REGIONAL LEADERSHIP INSTITUTE is a week-long comprehensive program that consists of a half day program on Sunday, four full-day programs Monday- Thursday and a morning program on Friday. Full-day sessions are generally held from 8 a.m. to 4:30 p.m. Participants are expected to arrive on Sunday, September 16 by noon and attend all sessions each day of the program. The class ends Friday, September 21 at 11 AM. THERE ARE NO EXPECTIONS.

Cost-The fee for the program is $1900.

Other- The class takes place at the King and Prince Resort on St.SimonsIsland. Lodging, program materials and most meals are included in the cost of tuition.

“I understand and will comply with the above Commitment Statements.”

Applicant SignatureDate

Application Deadline April 27, 2007

Please return to: REGIONAL LEADERSHIP INSTITUTE, Atlanta Regional Commission, 40 Courtland Street, Atlanta, GA30303. For more information, call (404) 463-3211. Fax (404) 463-3105.