LEADERSHIP NORTHWEST OKLAHOMA
APPLICATION
BIOGRAPHICAL
Last FirstMiddle(Preferred)
Name
City Zip
Home Address
Telephone (home)
Spouse’s Name (if applicable)
OCCUPATION/VOCATION
Employer/Vocation
Present Position
Business AddressStreet City & Zip Code
Business TelephoneFax No.
E-Mail Address
PREVIOUS EMPLOYMENT
Employer NameTitle or PositionDates EmployedResponsibilities
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EDUCATION
Beginning with high school:
Name and Location of SchoolDates AttendedDegreeMajor
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PROFESSIONAL ACTIVITIES
Please list vocational/professional organizations in which you have been active. (Do not include civic organizations, public office or political activity.)
Organization Dates of MembershipPosition held/responsibilities
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4
COMMUNITY OR STATE INVOLVEMENT
Please list your civic, religious, political, social, or other activities and note location.
OrganizationDates of MembershipPosition held/responsibilities
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LEADERSHIP ACHIEVEMENTS
What do you consider to be your most significant leadership contribution(s) or achievements(s) related to your occupation/vocation? (Limit your response to this space.)
What would you consider your most significant leadership contribution(s) or achievement(s) related to your community involvement, unrelated to your occupation/vocation? (Limit your response to this space.)
If your community involvement has been limited by circumstances in the past, please explain.
GENERAL
What is your vision for Northwest Oklahoma by the year 2020?
In your opinion, what strategies must be implemented to enable your vision to become a reality? How might you be involved?
AGREEMENT
I understand:
That completion of this application does not ensure my acceptance into the program.
That it is mandatory to attend all Leadership Northwest Oklahoma sessions and absence from more than one full session or from an accumulation of partial sessions equaling more than one session will make me ineligible to graduate.
That if selected I will devote the time necessary to complete this program. If appropriate, I have the approval and consent of my employer to participate in Leadership Northwest Oklahoma.
The commitments above and agree to be bound by them in signing this application.
SIGNATURES
ApplicantEmployer
DateDate
(This verifies the employer’s understanding of attendance.)
Please return the completed application to the Alva City Hall or John Barton, 810 College, Alva.
LEADERSHIP NORTHWEST OKLAHOMA
APPLICATION PROCESS
In order to be considered for selection for class I of LEADERSHIP NORTHWEST OKLAHOMA, applicants must complete allitems listed on this form. Please carefully review for any omissions before submitting. All applications are considered confidential and will be used only for the purpose of the selection process.
All applications must be postmarked or delivered no later than June 15, 2009. You will be notified of the Selection Committee’s decision by July 15, 2009.
Fees are due and payable prior to September 15, 2009 unless extended terms of payment have been approved.
COLLEGE CREDIT
Arrangements to enroll for three (3) hours of college credits for participation in this program have been approved by Northwestern Oklahoma State University. Additional responsibilities will be required for those persons who enroll for college credit. Northwestern is making arrangements for some college tuition scholarships for participants. Responsibility for enrollment and college tuition payment lies with the student and is separate from the following costs. If you wish to enroll for college credit please contact Steve Lohmann at (580) 327-8406.
FINANCIAL RESPONSIBILITY
The fee for the program is $250.00 which covers program costs, materials and meals. It does not cover college tuition costs if taken for college credit. Some financial assistance and extended terms are available on a limited basis. Requests for financial assistance will be considered on the basis of demonstrated need. If you wish to apply for financial assistance, please indicate the amount in need, the reason for your request and attach a copy of your 2008 tax return. It will be held in confidence.
For a complete review of the Leadership Northwest Oklahoma schedule, see reverse side.
LEADERSHIP NORTHWEST OKLAHOMA
Schedule for Class I 2009-2010
DATETIMECHAIRSUBJECT
Sept 15, 20096:00 – 8:00 PMJohn BartonOrientation
Sept 26, 20098:00AM-12:00PMScott Brown Team Building
Oct 13, 200912:00PM-5:00PMTrent GossLeadership
Nov 10, 200912:00PM-5:00PMNeal WilliamsEconomic Development
Dec 8, 200912:00PM-5:00PMJohn LastlyAgriculture
Jan 12, 201012:00PM-5:00PMJane BowenEducation/Youth, Diversity
Feb 9, 201012:00PM-5:00PMBarbara OestmannHealth Care/Soc. Services
Mar 9 & 10, 2010OvernightSteve Valencia State Government
Apr 13, 201012:00PM-5:00PMHelen BarrettCorrections/Media
May 4, 20106:00PM-8:00PMJohn BartonGRADUATION
The Workday will be determined by Class I ofLeadership Northwest Oklahoma.
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