Full Name: Preferred Name

Full Name: Preferred Name:

Mailing Address:

City: County: Zip:

How long have you lived in the county?

Gender: Ethnicity: Date of Birth:

Phone: E-mail:

Place of Employment: Position:

Years:

Which of the following best describes your present position? Please check one:

BusinessEducation (Secondary or Postsecondary)GovernmentIndustryNon-ProfitProfessionalReligionSocial ServiceVolunteerOtherIf Other, explain:

How did you learn about Advancing Sumter?

Have you ever participated in a leadership program? If so, when and where?

List your strongest leadership characteristics.

How can you benefit from further leadership training and development?

Describe your most significant professional and/or volunteer commitment(s) to date.

Include your position/involvement, the organization, and the date.

Please list other neighborhood, community and civic activities completed over the past five years:

Include your position/involvement, the organization, and the date.

What are the three most pressing issues facing Sumter County and why?

Describe how you plan to apply your enhanced skills and knowledge to benefit Sumter County.

Please list any interests you would like to explore that may contribute to the well-being of the community. Is there somewhere you might like to volunteer if you had more information about the entity, services offered? Is there an organization in the community you have heard of, but aren’t certain what they do? Is there a board you would be interested in serving on if you knew how to express your interest? Do you have a passion/interest that you would like to explore, but aren’t certain if there is an opportunity to do so locally?

Class Schedule

Advancing Sumter will meet every Tuesday for 12 weeks beginning Tuesday, January 20, 2015 and concluding with Graduation on Tuesday, April 7, 2015.

All classes will meet from 5:30pm until 8:30pm

All Advancing Sumter classes will be held at Georgia Southwestern University in the Student Success Center.

Tuition & Program Acceptance

Tuition for the program is $50.00

Please DO NOT send payment with your application.

Tuition will be payableupon notification of acceptance into the program.

All accepted applicants will receive information concerning payment and due date in an acceptance letter.

Applicants will be notified by December 8, 2014 of their acceptance into the program.

Application Info Deadline

Deadline: November 14, 2014

Incomplete applications will not be accepted or considered. Please make certain you have included all of the following items listed in the Application Check List below to insure your application is complete before submitting.

Completed Application Check List:

I have completed the Advancing Sumter Leadership Institute Questionnaire

I have attached a brief bio that is approximately one paragraph in length

I have attached a headshot/photo that can be used and reproduced in a directory format

Commitment/Consent:

I commit to attendat least 80% of the scheduled classes

I give my permission to use of my likeness in photographs, promotional materials and the like to further the

program and its mission.

Signature: ______Date: ______

Placing my signature above, I consent to the above statements and understand that my application will be considered incomplete if I do not submit all requested materials listed on the checklist above.

Mail application to:Americus-Sumter Chamber Commerce, PO Box 724, Americus, Georgia 31709

Attention: Advancing Sumter Leadership Institute or

Fax application to:229-924-8784 — Attention: Advancing Sumter Leadership Institute or

E-mail application to:

Subject Line: Advancing Sumter Leadership Institute