Jefferson Civic Leadership Application

Click HERE to view our Jefferson Civic Leadership Academy brochure!

Personal Information

First Name

Last Name

Address

City

State

Zipcode

Work Phone

Mobile Phone

Age

Work History

List most recent and relevant work experience(s) and position(s) held:

Business/Company/Organization

Position

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

I am currently employed here

Educational Background

List educational background, beginning with high school, including any college(s), advanced degrees and/or specific training.

School/Institution

Major

Area of study

Graduation Year

Degree Level

Awards and Honors
Detail the nature of the award and date received

Involvement in Civic and Volunteer Activities:

List, in order of importance to you, current community, civic, religious, political, social, and athletic or other activities in which you are or have been involved. Indicate your role in these activities.

Activity Role

Activity Description

What led you to apply for admission to the Civic Leadership Academy?

Please address your past leadership experience, what you hope to gain through the Civic Leadership Academy, what makes you an ideal fit for The Civic Leadership Academy, and what you believe your strongest contributions to The Civic Leadership Academy and team dynamic would be.

Describe below: Maximum of 500 words.

0/500 words.

WHAT LED YOU TO APPLY FOR ADMISSION TO THE RAIMY FELLOWSHIP PROGRAM?

Please address your present qualification as an emerging leader, how you plan to apply leadership theory and skills acquired in the program, and what makes you an ideal fit for The Raimy Fellowship Program

Describe below: Maximum of 500 words.

0/500 words.

References:

List three references, their contact information, and your relationship to them. References should be able to attest to your qualifications for The Civic Leadership Academy, and leadership experience and potential, as well as teamwork capacity.

The application should be received by the Jefferson Civic Leadership Academy no later than May 17, 2019 online, in person at the Jefferson, or mailed to:

Jefferson Educational Society
Attn. Ben Speggen
3207 State Street,
Erie, Pennsylvania 16508

Reference #1 (name, address, phone number, relationship to applicant)

Reference #2 (name, address, phone number, relationship to applicant)

Reference #3 (name, address, phone number, relationship to applicant)