CONFIDENTIAL APPLICATION FOR APPOINTMENT

Cross County Visionaries

I. PERSONAL DATA

Name ___________________ ___________________ ____________________________

Last First Middle

Age________ Male_____ Female______ Place of Birth_____________________ Race__________

Home Address _____________________________________________________________________

Number Street City Zip

Employer__________________________________________________________________________

Business Address____________________________________________________________________

Number Street City Zip Code

Home Phone________________ Business Phone________________ Fax #_____________________

E-Mail Address___________________________________________ Cell Phone_________________

Length of residence in Cross County_____________________________________________________

If not a resident, how long employed in Cross County_______________________________________

Spouse's name if applicable_________________________ # of Children_____________________

Children's names and ages____________________________________________________________

__________________________________________________________________________________

Leisure Activities____________________________________________________________________

One unusual or "fun" fact about yourself_________________________________________________

Please attach a photo of yourself

II. EDUCATION

(List in order high school, college(s), advanced degrees and/or specialized training)

School Name and Location Dates Attended Degree Major

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Special Awards/extracurricular activities (Leadership positions held, special honors and awards received).

__________________________________________________________________________

III. EMPLOYMENT

Present Employer______________________________________Date of Hire____________________

Type of Business or Organization_________________________Title___________________________

A. Briefly describe your employment responsibilities_______________________________________

__________________________________________________________________________________

B. List previous employment in reverse chronological order (include active military duty.)

Employer Title/Responsibility From To

__________________________________________________________________________________

__________________________________________________________________________________

C. What have you done (anywhere, anytime) that has demonstrated that you care about your community? ________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

D. What kind of volunteer activities would you like to become active with in the future?

E. If you have not had time or interest to become actively in the past, what conditions have changed now that enables you to seek involvement in the community?_________________________________

____________________________________________________________________________________________________________________________________________________________________

IV. GENERAL INFORMATION

One of the goals of Cross County Visionaries is to build a network of community leaders who can enhance their problem solving and other leadership abilities through shared perspectives and working together. In that view, please answer the following questions.

A. What do you feel are the three most significant problems facing Cross County?

____________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________

What do you feel needs to be done on one of these issues? _______________________________

__________________________________________________________________________________

C. What are the three most notable opportunities the Cross County area has to offer?

____________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________

What do you think needs to be done to develop one of these?

E. How do you think your participation in Cross County Visionaries will enhance your community?

F. Reference (Attach one letter of reference /non-related individuals)

V. COMMITMENT

To graduate from Cross County Visionaries, a participant is expected to attend all sessions. If accepted into the Cross County Visionaries program, you or your employer/sponsor will be billed $250 per person for the tuition fee (payable prior to the first session), which covers all program costs.

"I understand the purpose of the Cross County Visionaries program, and if I am selected, I will devote the time and resources necessary to complete the program. Furthermore, even though emergencies do arise, I understand if I have more than two absences I may be asked to withdraw from the program and no portion of the tuition shall be refunded. I understand the above commitment and agree to be bound by it in signing this application."

__________________________________________________ ________________________

Applicant Signature Date

______________________________

Cross County Visionaries

SELECTION CRITERIA

Participation in the leadership program is open to persons living or working in Cross County. A maximum of 15-20 individuals will be selected to participate in the program. Selection will be based on the following criteria:

1. A strong interest and commitment to serve Cross County beyond the training period.
2. The willingness to devote time to the program both in terms of attendance and class projects.
3. A demonstration of leadership skills and abilities on the job.
4. Community and/or civic service leadership as evidenced by the level of involvement in non-employment-related volunteer activities; or demonstration of interest in becoming more involved.
5. Ability to make substantial contribution to the program both in terms of issues and projects, as well as networking with peers.
6. Financial and time commitment of your employer or sponsoring organization.

Participation will be chosen by a selection committee based on the information completed on the application and accompanying letter of recommendation. Since the number of appointments is limited, applicants who are not selected will automatically be enrolled in the following year's class.

The committee will be seeking representatives from a cross section of the community.

EMPLOYER COMMITMENT FORM

Note: This document is to be completed by an employer.

If self-employed or not employed

you may skip the employer commitment section.

Applicant's Name_________________________________________

Employer Name___________________________________________

Employer's Title/Company________________________________________

Company Address_________________________________________

_________________________________________

I understand that, if selected_____________________________________ will

(Applicant Name)

participate in the Cross County Visionaries program, and will be attending seminars and participate in other activities during the next year. This will require approximately 8 days away from work. Arrangements will be made to relieve him/her of assigned duties in order to participate in this training program. I understand that the purpose and value of the program is to develop and educate leaders and hereby offer my support and encouragement.

Employer Signature___________________________________ Date___________