Course Application Form 2023

A fee of $25.00 is required to submit this application through April 29, 2023, after that date the application fee increases to $50.00

APPLICANT INFORMATION

* First Name (50 char)

* Last Name (75 char)

* E-Mail Address (255 char)

* Mailing Address (100 char)

* City (75 char)

* State

* Zip Code (15 char)

* Phone - Home (50 char)

Phone - Work (50 char)

* Phone - Cell (50 char)

* Have you participated in and/or graduated from another leadership Program? If “Yes” where? Please answer below.

Yes
No

Participation City (255 char)

Participation State (20 char)

Participation Year (10 char)

Attach Resume/Answers (optional) : For the Employment, Volunteer and Educational background or any other fields in this applicationw, you may attach your resume/answers using this link. If you choose to do so, please reference your resume in the form field, as these are required fields.

VOLUNTEER POSITIONS, ACTIVITIES, AND ACCOMPLISHMENTS

* Please list dates, organization, positions held, duties, accomplishments and supervisor. (500 char)

Current Employer

* Please list your current employer, position/title, and how long you've served in this position (500 char)

Optional Previous Employer and Resume (500 char)

Educational Background

* Please list institution, name & location, # years, grad. year, major course of study and degree (500 char)

* Have you been convicted of a felony?

No
Yes

LEADERSHIP INTERESTS, GOALS & OBJECTIVES

* Briefly discuss your leadership interests, goals and objectives. (500 char)

* Describe the community or civic subject that interests you the most. (500 char)

* What would you most like to contribute to the Mesa Community? (500 char)

* What do you expect to gain from participation in the Mesa Leadership Program? (500 char)

MESA’S COMMUNITY CHALLENGES

* Briefly discuss three opportunities and/or problems facing the Mesa community today. (500 char) Your answer to this question helps us to focus on those areas of interest to our class.

References

References are required from two people who can be contacted to provide knowledge of your qualifications as a Mesa Leadership applicant. Please do not use family members as references. It’s preferred that references are in the local area.

* 1. Name (255 char)

* 1. Phone (255 char)

* 1. E-Mail (255 char)

* 2. Name (255 char)

* 2. Phone (255 char)

* 2. E-Mail (255 char)

Scholarship

The Program tuition of $1,500 is due by July 1st to participate in the program. Mesa Leadership offers 2 partial scholarships in the amount of $750 each. Do you require a scholarship to participate?

Yes
No

Please briefly describe your need and why tuition assistance would impact your ability to participate in the program.

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