First Name * Last Name * Preferred First Name Middle Name Employer * Job Title * Bus. E-Mail * Home E-Mail * Home Phone * Cell Phone * Bus. Phone * Bus. Fax Work Address * Work City * Work State * Work Zip * Home Address * Home City * Home State * Home Zip * Emergency Contact * Relationship * Cell Phone * Phone * Birthdate * Gender * MaleFemale Ethnicity * Asian PacificAfrican AmericanCaucasianHispanicNative AmericanI do not wish to disclose this informationOther Do you have any special dietary needs or will you require special accommodations? YesNo Please Indicate TYPE OF ORGANIZATION/BUSINESS WHICH BEST DESCRIBES THE AREA(S) IN WHICH YOU PRESENTLY WORK/SERVE Advertising/Marketing/Public RelationsEducationMediaArtsEnvironmentalNon-Profit/Community VolunteerAutomotiveGovernmentPersonnel & Employment ServicesBanking/Financial/InvestmentHealth Care (Large Institutions)Real Estate & Property ManagementChamber of Commerce/Trade AssociationHuman ServicesRecreationClergy/ReligiousInsuranceRetail & SalesCommunicationsInterior Design & FurnitureSmall BusinessComputer & RelatedLegalUtilityDesign & ConstructionManufacturingOther CAREER HISTORY List previous employment in reverse chronological order (include active military duty) Employer City/State Title/Responsibility From - To Employer City/State Title/Responsibility From - To Employer City/State Title/Responsibility From - To PROFESSIONAL/BUSINESS ASSOCIATIONS AND COMMUNITY INVOLVEMENT Organization Position(s) or Assignments Approximate hours per month Organization Position(s) or Assignments Approximate hours per month Organization Position(s) or Assignments Approximate hours per month MILITARY SERVICE Have you served active duty or reserve time in the US Military? YesNo Dates PROFESSIONAL AND CIVIC AWARDS AND RECOGNITION Recognition/Award Awarded By Date What do you consider your most important civic contribution and why? * GENERAL INFORMATION How would your participation help promote diversity in the makeup of the class? * 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? * General Information Continued Live in Oakland County? Work in Oakland County? Other? What specific skills/knowledge do you hope to gain from your Leadership Oakland experience? * I am being nominated by A graduate of Leadership Oakland Name Phone Self (Please list a personal reference) Name Phone Other Name Phone List all Chamber of Commerce affiliation(s) (individual/business) SELECTION CRITERIA Application to LEADERSHIP OAKLAND CORNERSTONE PROGRAM is open to all persons living or working in Oakland County and the Detroit metropolitan area. The class is generally limited to 35-50 participants who will be selected by the LEADERSHIP OAKLAND Selection Committee. The Committee will be seeking participation from varied business, ethnic, minority, age and gender groups to represent a cross-section of the community. Participants should be active in business, and/or professional, educational, organized labor, 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 community. 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 Currently in or potential for advancement to top leadership positions within their own organization 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 overnight retreat and at least 80% of the monthly sessions is a prerequisite for graduation TENTATIVE PROGRAM DATES APPROXIMATE TIMES Leadership Development - Overnight Retreat SEPTEMBER 11-13, 2016 SUN PM – TUES AFTERNOON ECONOMY & GOVERNMENT OCTOBER 5, 2016 7:30 AM TO 5:00 PM NON-PROFITS & HUMAN SERVICES NOVEMBER 9, 2016 7:30 AM TO 5:00 PM HEALTH & ENVIRONMENT DECEMBER 14, 2016 7:30 AM TO 5:00 PM DIVERSITY & INCLUSION JANUARY 11, 2017 7:30 AM TO 5:00 PM JUSTICE SYSTEM FEBRUARY 8, 2017 7:30 AM TO 5:00 PM EDUCATION MARCH 8, 2017 7:30 AM TO 5:00 PM ARTS & CULTURE APRIL 12, 2017 7:30 AM TO 5:00 PM SHAPING THE FUTURE MAY 10, 2017 7:30 AM TO 5:00 PM CLASS PROJECT DATE TBD BY LOXXVII 7:30 AM TO 5:00 PM GRADUATION JUNE 14, 2017 (TENTATIVE) 4:30 PM TO 8:00 PM CORNERSTONE PROGRAM TUITION Tuition for Leadership Oakland XXVII is $3,250 and covers all program costs and materials, including room and meals at the Leadership Development overnight retreat. A deposit of $250 is required with this application and upon acceptance to the program 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.* Deposits are only refunded if you are not selected to participate by the LO Selection Committee. REFERENCES Name Title Organization Phone Name Title Organization Phone CORNERSTONE PROGRAM APPLICANT COMMITMENT If selected as a participant in Leadership Oakland XXVII, I will attend the Leadership Development overnight retreat and at least 80% of the monthly sessions. I will also make every 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. E-signature (Full Name) Sign Date Refund / Cancellation Policy Cancellations are subject to a $250 materials fee. Cancellations must be made in writing to Leadership Oakland no later than 30 days in advance of the opening retreat to receive a full refund (less $250 materials fee). Cancellations after this date will be subject to refund as follows: 29-15 days 80%; 14-7 days 50%; 6-0 days 0 refund. INSTRUCTIONS • *If you wish to apply for a scholarship, a letter indicating the reason and amount requested must be included with your application. • Upload electronic photo (preferably as a JPEG) at time of application.