Application Form "*" indicates required fields Title*Mr.Mrs.Ms.Dr.Sr.Hon.First Name* Middle Initial (or Name) Last Name* Suffix Contact InformationPreferred Email* Alternate Email (If Applicable) Primary Phone*Phone Extension (If Applicable)Phone Type*HomeWorkCellSecondary Phone(If Applicable)Phone Extension (If Applicable)Phone Type*HomeWorkCellAddressCompany Name (If Applicable) Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Zip +4 Address Type*HomeWorkEmployment InformationCurrently Employed* Yes No Self Employed Employer/Company Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Zip +4 How long have you lived/worked in Rockland County?* LeadershipPlease list any leadership experience, including organizations and positions held.*Please list any awards, honors, or special recognitions you have received for your leadership experiences.*Name someone you consider an outstanding leader. What leadership qualities do they exhibit?*What you consider your strongest leadership attributes?*ServicePlease list your community services activities and/or volunteer commitments. Please include positions held and your length of service for each organization.*Are any of your community service/volunteer activities related to your employment? If yes, please explain.*What do you consider your most significant service experience?*EssayPlease limit your essay response to no more than 500 words.In your opinion, what do you believe to be the most important issue or concern facing Rockland County?*Supplemental InformationWhy do you want to participate in the Leadership Rockland program and what do you expect to get out of the program?*List any additional information you feel is relevant to your application that you would like us to know and consider.How did you learn about Leadership Rockland?*Scholarship InformationLeadership Rockland offers a limited number of partial scholarships for applicants who require financial assistance. We encourage applicants to also seek funding from other sources. Do you have a financial need for a partial scholarship?* Yes No If you are not awarded a scholarship, will you still be able to participate in the program if accepted?* Yes No Please explain the circumstances that make you apply for a scholarship based on need.*Additional Application MaterialsRésuméPlease upload a copy of your resume/CV/bioResumeAccepted file types: doc, docx, pdf, Max. file size: 128 MB.ReferencesApplicants must submit at least two (2) personal recommendations from people who are knowledgeable about your leadership performance or potential. The best applications will have recommendations from different organizations. Please limit recommendations from Leadership Rockland board of directors to one. (See list at http://www.leadershiprockland.org/about/board-of-directors/.) Please provide the names and email addresses of the two people you have asked to provide a reference. Please advise your references that Leadership Rockland will email them the reference link directly. Reference #1* Reference #1 Email* Reference #2* Reference #2 Email* Application Fee or WaiverThere is a $25 non-refundable application fee to apply to the program. This fee may be waived in whole or in part for those who have paid to attend any Leadership Rockland events between September 1st of last year and May 1st of this year. Based on the above, are you eligible for the application fee waiver?* Yes No If yes, what event(s) did you attend? Include approximate date and location.* PaymentPayment of the application fee can be made online (preferred method). Payment can also be made by check payable to Leadership Rockland, Inc. After you submit your completed application, you will receive further details on paying the application fee.Sign and Submit ApplicationIf you are willing to make a commitment to attend each of the 11 sessions from September through June, and you understand the tuition requirements, please so indicate with your signature. By signing you understand that you are committing to the terms of the program participation. By checking this box each party agrees that the electronic signatures, whether digital or encrypted, of the Applicant submitting this Application are intended to authenticate this writing and to have the same force and effect as manual signatures. Signature Acknowledgement* Print Full Name* Δ You can pay the application fee of $25 here Pay Application Fee If you prefer, you can also mail a check made payable to Leadership Rockland to: Leadership Rockland, Inc. P.O. Box 459 New City, NY 10956