Cornerstone Program Application PhoneThis field is for validation purposes and should be left unchanged.Name First Middle Last Preferred First NameEmployerJob TitleBusiness Email Personal Email Business PhoneCell PhoneBusiness Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Preferred Address Business Home Preferred Phone Business Cell Birthdate Emergency ContactEmergency Contact RelationshipEmergency Contact Cell PhoneRace White Black or African American American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Multiple Races Other Race Prefer not to answer If other, please specifyGender Male Female Transgender Female Transgender Male Gender Variant/Non-conforming Other Prefer not to answer If other, please specifyCheck the type of Organization/Business which best describes the area(s) in which you presently work/serve. Accounting/Finance Advertising/Marketing/Public Relations Arts Automotive Banking/Financial/Investment Biotech Chamber of Commerce/Trade Association Clergy/Religious Construction Education/Training Environmental Government/Military Healthcare Human Services Insurance Legal Manufacturing/Operations Media (Newspaper/Publishing/Television/Radio) Nonprofit Real Estate/Property Management Recreation Retail Sales Small Business/Entrepreneur Staffing/Employment Services Technology Telecommunications Utility Other If Type of Organization/Business is Other, Please specifyCareer History- Please attach a resume in pdf format.Accepted file types: pdf, Max. file size: 256 MB. Have you served active duty or reserve time in the U.S. Military? Yes No If yes, what were your dates of service?Professional and Civic Awards and RecognitionPlease list any recognition or awards you have received, who awarded them and the date they were awarded.What do you consider your most important professional/civic contribution and why?In your opinion, what are the three most significant challenges facing Oakland County and/or the region?In your opinion, what are the three most notable opportunities Oakland County and/or the region has to offer?How would your participation help promote diversity in the makeup of the class?How do you envision Leadership Oakland helping you achieve your leadership goals?Do you live and/or work in Oakland County? Live Work Both What specific skills/knowledge do you hope to gain from your Leadership Oakland experience?I am being nominated by: Self A graduate of Leadership Oakland Other (please explain) If you are being nominated by a Leadership Oakland Graduate or someone else, please list their name and email below.If other, please explain.Consent I understand the selection criteria, attendance requirements and the tuition and deposit information.SELECTION CRITERIA Application to the LEADERSHIP OAKLAND CORNERSTONE PROGRAM is open to all persons living or working in the Detroit metropolitan area. The class is generally limited to 50 participants who will be selected by the LEADERSHIP OAKLAND Selection Committee. The Committee will be seeking participation from a cross-section of the community. Participants should be active in business, and/or professional, educational, governmental, artistic, religious, service or community organizations. The most important factor in selection is identifying those individuals most apt to utilize their leadership for the long-term benefit of the region. In reviewing applications, the Selection Committee looks for candidates who demonstrate the following characteristics: • Genuine concern for the future of Oakland County and the region • A sincere commitment, motivation and interest to serve Oakland County and the region • Willingness and ability to make the time commitment required by the program • The intention of seeking appointments to community boards, commissions or key volunteer leadership positions • Representative of the diversity of the region We strive to model and promote diversity and inclusion as a means to strengthen leadership. We do this by: respecting and encouraging all perspectives; and engaging diverse populations in all activities. ATTENDANCE REQUIREMENT Attendance at the retreat and at least 75% of the monthly sessions is a requirement for graduation. Participants must attend the retreat and can't miss more than 2 monthly sessions to be eligible to graduate. CORNERSTONE PROGRAM TUITION Tuition for Leadership Oakland Cornerstone Program is $3,995 and covers all program costs and materials. A deposit of $250 is required with this application; upon acceptance to the program, it will be applied to the tuition. Tuition must be paid in full 60 days from the date of acceptance to the program, unless other payment arrangements have been made. A limited number of scholarships are available to qualified individuals who may not otherwise be able to participate. If you wish to apply for a scholarship, email a letter with the reason to info@leadershipoakland.com. Deposits are only refunded if you are not selected to participate by the LO Selection Committee. Reference 1 First Last OrganizationOrganizationPhonePhoneReference 2 First Last OrganizationOrganizationPhonePhoneCORNERSTONE PROGRAM APPLICANT COMMITMENT I agree to the Cornerstone Program Applicant CommitmentIf selected as a participant in Leadership Oakland Cornerstone Program, I will attend the Leadership Development retreat and at least 75% of the monthly sessions. I will also make an effort to attend other functions sponsored by the program. I agree to respect and abide by the rules of host locations throughout the program. I understand that if I fail to meet any part of this commitment, I may be asked to withdraw from the program without any refund of tuition. I understand that any false information may disqualify me from participation.My employer or organization is sponsoring my enrollment in Leadership Oakland. Yes No If you are sponsored, please provide the name, title, organization and contact information of the organization that is sponsoring you below.Refund/Cancellation Policy I agree to the refund/cancellation policyREFUND/CANCELATION POLICY Cancellations are subject to a $250 registration fee. Cancellations must be made in writing to Leadership Oakland no later than 45 days prior to the opening retreat to receive a full refund (less $250 registration fee). Cancellations after this date will be subject to a prorated refund as follows: 45-30 days 50%; less than 30 days 25% refund.
