APPLICATION
DEADLINE: APRIL 30th

Due to the significant number of individuals seeking participation in the LNV program, the LNV Board will complete a two-step process to select the upcoming class. LNV Board will utilize this application to evaluate each applicant's leadership profile using consistent criteria pre-determined by the Board. Based on this initial evaluation, a certain number of candidates will then be selected to participate in an oral interview process. After the oral interview process, 28 individuals will be selected to participate in the upcoming class.

1. RESIDENCE
Last Name
First Name
Middle Name
Name or Nickname
Home Street
Home City
Home Zip
Phone
Fax
Cell
Email
2. EMPLOYMENT
Present Employer or Business Name
Business Name
Business Street
Business City
Business Zip
Phone
Fax
Email
Type of Business
Position/Title
Hire Date
Briefly Describe Your Responsibilities
Previous Employment
Employer
Title/Responsibilities
From/To Dates
Employer
Title/Responsibilities
From/To Dates
Employer
Title/Responsibilities
From/To Dates
3. EDUCATION
Name/City of School
Dates
Degree
Major
Name/City of School
Dates
Degree
Major
Name/City of School
Dates
Degree
Major
4. ORGANIZATIONS/ACTIVITIES/COMMUNITY INVOLVEMENT
A. Please list, in order of importance to you, three community, civic, professional, business, religious, social, athletic, and/or other organizations of which you have been a member. Please describe the nature of your participation, responsibilities, accomplishments, and/or awards/recognition you received.
Name of Organization
Dates of Involvement
Position Held
Describe
Name of Organization
Dates of Involvement
Position Held
Describe
Name of Organization
Dates of Involvement
Position Held
Describe
B. If you have previously not participated in community activities, what conditions have changed that now enable you to seek involvement in the community and in what specific activities will you seek involvement?
C. Describe how you believe your participation in the Leadership Napa Valley Program will enhance your ability to become personally involved in activities and/or organizations in Napa County.
D. Years you have lived in Napa County: . Do you expect to be living in and actively involved in the Napa County area in 5 years?  Yes   No. Explain in detail as to why you see yourself actively involved, in what areas, and why in Napa County.
5. GENERAL
A. In your judgement what are two pressing problems facing the Napa County area today and why?
B. What do you hope to gain through your participation in the Leadership Napa Valley Program?
6. REFERENCES
Please provide the names of three business and/or personal references that could be contacted.
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
7. TUITION
Tuition is $1,195.00. If selected for Class 26, a $200 non-refundable deposit personally paid by you is due with your written acceptance. The $995 balance of the tuition may be paid by any club, organization, business, employer, or by you. This $995 balance is due as follows: $500.00 on or before September 1, 2012 and $495.00 on or before November 1, 2012. Please indicate how your tuition will be paid:
If selected, would you be interested in applying for scholarship assistance from LNV? (If you indicate Yes and are selected to the program you will receive a scholarship application form.)
   

8.

SIGNATURES
Full participation in this program is critical. If selected, I make a commitment to meet all time, financial, and participatory requirements of the program.
Date
I understand the importance of full participation of the applicant, and if he/she is selected to participate, then I, as the Employer, will provide release time from work and will help him/her meet the requirements.
Date
(Employer's Signature, if not self-employed)
 

Please print and review your application before submitting it. You will have an opportunity to make changes prior to your final submission.
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