LEADERSHIP BELLEVILLE 2008-2009

I. CONFIDENTIAL APPLICATION

All applications will be handled in the strictest confidence. As a matter of policy, LEADERSHIP BELLEVILLE does not discriminate among applicants and participants on the basis of race, religion, sex, age or disability.

Please complete this application thoroughly and legibly. Include the information requested about yourself, which you believe to be the most outstanding and relevant. Use a separate sheet if necessary. Applicants may attach additional pages or a resume if so desired in response to the following questions.

This application also requires an essay on why each applicant feels they should be accepted into the program. Please include information regarding your leadership strengths and qualifications, in detail.

All applications must be received by August 8, 2008. All 2008/2009 applicants will be notified of program participation by August 15, 2008.

Name:

(Last) (First) (Middle)

Preferred First Name: Date of Birth:

Home Address:

(Street) (City) (State) (Zip)

Company Name:

Company Address:

(Street) (City) (State) (Zip)

Home Phone: Business Phone:

Email: Business Fax:

II. PARTICIPATION

Required Attendance

· A two-day retreat on September 18 & 19, 2008.

· Eight full-day sessions (8:00am – 5:00pm) ending in May 2009.

Tuition

Member Tuition for each participant accepted into Leadership Belleville is $975. The price for non-members is $1200. The participant, the participant’s employer or a sponsoring organization, may pay tuition. Tuition is to be submitted upon notice of acceptance into the program and payable prior to August 25, 2008.

Name, address and phone number of company, organization or individual nominating you. Otherwise indicate self-nomination. Self-nomination will receive equal consideration.

Sponsored Self-nominated

III. REFERENCES

List two persons who have knowledge of your qualifications as a LEADERSHIP BELLEVILLE candidate.

1. Hm:

Bus:

2. Hm:

Bus:

IX. ACKNOWLEDGEMENT

I understand the purpose of the LEADERSHIP BELLEVILLE program and that the completion of this application does not ensure my acceptance in the 2008-2009 class. If selected, I have company/organization support for my participation, where applicable, and I will be able to attend all seminars. If selected, I will arrange for payment of the $975 member or $1200 non-member tuition fee to LEADERSHIP BELLEVILLE on or before August 25, 2008. I understand that tuition is non-refundable.

Please check the appropriate box:

€ My organization is prepared to cover the tuition requirement if I am accepted.

€ My organization will not cover the tuition requirement, but I guarantee that the fee will be paid if I’m accepted.

I certify that all of the statements made in this application are true, complete and correct to the best of my knowledge and are made in good faith. I know and understand that all items herein may be verified.

(Applicant Signature) (Date)

I have reviewed this application and understand the time and financial commitment it represents. We agree to support LEADERSHIP BELLEVILLE and these commitments if our candidate is selected.

(Employer’s Signature) (Date)

(Title) (Company)

Applications must be received by the Chamber office by August 8, 2008.

You will be notified of your participation status by August 15, 2008.

Please send your application to:

Greater Belleville Chamber of Commerce

216 East “A” Street

Belleville, IL 62220

(618) 233-2015 Fax (618)-233-2077