KLA Application Form

KLA Class Application
Personal Data
Legal Name

First NameLast Name
Preferred Name for Name Tag
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Number Of Years Living and/or Working in Kosciusko County
Personal Email Address
Employment
Present Employer
Date of Hire
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Telephone

Area CodePhone Number
Title/Responsibility
Name of Supervisor

First NameLast Name
Business E-mail Address
Employment History

List Previous Employment, Starting With The Most Recent (Include Active Military Duty)
Employer Name
Title/Responsibility
Dates Of Employment
Employer Name
Title/Responsibility
Dates Of Employment
Employer Name
Title/Responsibility
Dates Of Employment
Employer Name
Title/Responsibility
Dates Of Employment
If you more to list, please use this box.
What do you consider your most important career accomplishment to date?
How many days per month does your work require you to be out of town?
Education
Name of School & Location
Dates Attended
Degree/Major
Name of School & Location
Dates Attended
Degree/Major
Name of School & Location
Dates Attended
Degree/Major
Name of School & Location
Dates Attended
Degree/Major
If more to list, please use this box.
Community Involvement

Please list, in order of importance to you, up to five (5) civic, professional, religious, community, athletic, social or other organizations of which you are a member. Please note any leadership positions held.
Organization
Title/Responsibility
Dates of Membership
Organization
Title/Responsibility
Dates of Membership
Organization
Title/Responsibility
Dates of Membership
Organization
Title/Responsibility
Dates of Membership
Organization
Title/Responsibility
Dates of Membership
What do you consider to be your most important community service responsibility or accomplishment, in or outside Kosciusko County, to date?
Hou much personal time each month do you commit to community, civic and professional activities?
On what kinds of community boards, committees or groups would you like to become active in the future?
If you have previously not had time or interest to become actively involved, what conditions have changed that now enable you to seek community involvement.
General Information
What are your reasons for desiring to participate in the Kosciusko Leadership Academy program?
How do you feel you can contribute to the program?
What do you hope to gain from your participation in the Koscuisko Leadership Academy and how do you expect to utilize your KLA experience?
Recommendations

Personal References. Please list two (2) persons other than your sponsor who are knowledgeable about your leadership performance and potential.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Organization
Title
Name

First NameLast Name
Phone Number

Area CodePhone Number
Organization
Title
Finances

If selected, payment of tuition will be made by each participant or financial sponsor. Tuition is due and payable by the first day of class.
If being sponsored by a company, please enter company name:
Name of person tuition bill should be sent to:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Scholarship Policy: There is only one (1) scholarship available per year. This may be given to one (1) individual or divided between two (2) individuals.
Do you require financial assistance in order to participate in KLA?

YesNo
If you do not have a corporate sponsor and do not receive the scholarship, are you willing to pay the full cost of tuition yourself?

YesNo
If no, please explain circumstances:
Commitment
Enter code word to verify application and hit submit. You may also print a copy of this application for your records.*
By entering my name below I am agreeing that if selected as a participant, I am willing to attend all the programs, will complete a white paper and complete other assignments required by the program. I understand that if I fail to meet any part of this obligation, I may be asked to either withdraw from the program or make up missed sections the following year.

First NameLast Name
Please print a copy prior to submitting this application to keep for your records!
Should be Empty:

KLA Class Application

Personal Data

Employment

Employment History

Education

Community Involvement

General Information

Recommendations

Finances

Commitment

Please print a copy prior to submitting this application to keep for your records!