Application Form TitleMr.Mrs.Ms.Dr.Sr.Hon.First Name* Middle Name Last Name* Suffix How long have you lived and/or worked in Rockland County?* Home AddressAddress* 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 Contact InformationEmail (Preferred)* Email Type* Personal Business Home Phone*Cell Phone*FaxWork PhoneExtension Email (Alternate) Employment InformationAre you currently employed?* Yes No Employer* Title / Position* Years / Months* Work 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 Are you self-employed or do you work for someone else?* Self Employed Work for someone else N/A Employment Supervisor Supervisor's Title Supervisor's Email Supervisor's PhoneExtension LeadershipPlease list any leadership experience, including organizations and positions held.*Please list any awards and/or honors for leadership activities or academic excellence. You may also list any special achievements accomplished from any of your leadership experiences.Name someone you consider an outstanding leader. What qualities of leadership do they exhibit?*What do you consider to be your strongest leadership attributes?*Community ServicePlease list your community service activities and volunteer commitments in order of their importance. Include level of capacity in which you serve and the number of hours per month related to each activity.Indicate if any of the above community service activities are related to your employment. If you are paid to attend or participate by your employer or it is a mandatory condition of your employment those activities would be considered work related.What do you consider to be 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?*List any additional information you feel relevant to your application. Also list any information that did not fit in any prior part of the application.Why do you want to participate in the Leadership Rockland program and what do you expect to get out of the program?*How did you hear about Leadership Rockland?* Scholarship InfoLeadership Rockland has a limited amount of partial scholarships available for applicants who require financial assistance. We expect applicants to seek funding from other sources prior to requesting tuition assistance from Leadership Rockland. To help us assess the anticipated resources required for each class, please complete the following questions. Those seeking scholarships will receive further instructions once their application has been reviewed.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 Scholarships are based on financial need. Please explain the circumstances that make you apply for a scholarship based on need.*Application Fee 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 April 1st of the year in which the application is being submitted. The fee may also be waived if you previously paid a fee to apply for the Leadership Rockland program in a prior year. Based on the above, are you entitled to a waiver of your application fee?* Yes, I qualify for a waiver No, I do not qualify for a waiver I will be paying the application fee: Online By Check If you answered yes, please fill in the amount you paid and the event(s) you attended, or the year in which you previously applied and paid the application fee.File UploadsFiles uploaded below must be in .doc, .docx, or .pdf format only.Résumé/CV/BioLast Name First Name Filename (Jones Tom Résumé)Max. file size: 128 MB.Application Signature PageLast Name First Name Filename (Jones Tom Signature Page)Max. file size: 128 MB. 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
