Leadership Liberty Application

"*" indicates required fields

Your Personal Information

Your Name*

First Last Preferred Name on Materials

Your Email Address*

Enter Email Confirm Email

Employment*

Company Title / Position Time at Current Position

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Work Phone*

Personal Cell Phone*

How long have you worked / lived in the Liberty Area?*

Headshot / Professional Photo*

Please upload a photo.

Max. file size: 16 MB.

Photo Permission*

If accepted into the program, I permit my photo to be taken on program days & used on the Liberty Area Chamber of Commerce website and in Leadership Liberty marketing materials.

Additional Information

How did you learn about Leadership Liberty?*

Liberty Area Chamber of Commerce

Employer

Social Media

Friend

Education Information*

Please list your educational achievements in order of most recent (degrees, certificates, etc.).

Institution / Organization

Date Attained

Degree / Major / Certificate

Business / Professional Information*

What leadership experience do you have? Please list your top three business/professional involvements: government, civic, charitable, religious, social, or other.

Organization

Position Held

Describe Responsibilites

Years Involved

Have you received any special awards or achievements?

What do you hope to gain from this program?*

References*

Please provide two letters of recommendation. One from your company’s leadership or your direct supervisor. The other letter should be from an individual (other than an employer or spouse). Contact information is required for both references.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 2.

Agreements

Employer Agreement*

Employers are in a position to recognize leadership potential. Therefore, applicants for Leadership Liberty must have their employer's full support and commitment because attending every session is mandatory to complete the program. The signature of the applicant’s manager or head of the organization is needed below. This applicant has my support for the time commitment required to actively participate in the Leadership Liberty program. I have reviewed the program dates and agree the employee will be able to attend and will have limited communication access during all sessions.

Applicant Agreement*

If selected as a participant in the Liberty Leadership program, I am committed to attending and participating in all sessions sponsored by the program. I understand that contact with my office will be limited during sessions.