Apply to Leadership-Baltimore County

Confidential Information for Appointment

I. Personal Data

Date

First Name

Middle Name

Last Name

Nickname Preferred

Spouse First Name

Home Address

City

ZIP Code

Home Phone

II. Employment

Present Employer

# of Years

Present Title

Phone

Business Address

City

State

ZIP Code

Fax

A. Brief description of responsibilities

B. Business/Professional Affiliations (if any)

Name of Group

Positions Held or Assignments

Name of Group

Positions Held or Assignments

Name of Group

Positions Held or Assignments

III. Education

(Begin with college(s), advanced degrees and/or specialized training)

School Name, City, State

Degree

Major

School Name, City, State

Degree

Major

School Name, City, State

Degree

Major

IV. Community Involvement

A. Include community, civic, religious, political, governmental, social, athletic, or other activities. Do not include business/professional activities. Indicate major role in the organization at this time.

Organization

Assignment/Position

Describe Responsibilities

Organization

Assignment/Position

Describe Responsibilities

Organization

Assignment/Position

Describe Responsibilities

B. What do you consider your most important accomplishment in one of the above organizations? Why?

C. How much time each month do you commit to volunteer work?

D. What kinds of volunteer activities would you like to become active with in the future?

V. General Information

(One of the goals of Leadership-Baltimore County is to build a network of community leaders who can enhance their problem-solving and other leadership abilities through shared perspectives and working together.)

A. What do you feel are the three most significant problems facing the greater Baltimore area today?

What do you feel needs to be done about one of these issues?

B. What specific skills/knowledge do you hope to gain from your participation in Leadership-Baltimore County?