GDMLI Community Leadership Application Form

General Information  (* indicates Required Field)
(Please use legal name as it appears on photo ID, which is required for airport check-in.)
First Name*
 
Last Name*
 
Address1*
 
Address2
City*
 
State*
 
Zip*
 
Home Phone*
 
Email*
   
Additional Information (* indicates Required Field)
Business/Organization *
 
Business/Org. Address *
 
Business/Org. City *
 
Business/Org. State *
 
Business/Org. Zip *
 
Business/Org. Email
 
Business/Org. Phone *
 
Business/Org. Fax
Description of Business/Org. *
 
Years in Metro Area *
 
Current Employment (* indicates Required field)
Position/Title *
 
Job Responsibilities *
 
What do you consider your highest responsibility, skill, or career achievement to date? *
 
Previous Employment (* indicates Required Field)
Briefly describe previous positions held (in the past ten years) *
 
Educational Background (* indicates Required Field)
Include dates of attendance, institutions, field(s) of study, and degrees awarded. Please include any relevant professional institutes, training programs, etc. *
 
Organizations and Activities (* indicates Required Field)
Please list, in order of importance to you, the major civic, business, and professional activities in which you have participated during the last several years. Activities need not be limited to those in the Des Moines area. For each activity, indicate the organization, approximate dates of membership, extent of your involvement including offices held, awards received, and/or special recognition given.

If you have not been involved in such activities, please explain.
Professional Based Organizations/Activities, Approximate Dates of Membership, and Involvement *
 
Community and Service Based Organizations/Activities, Approximate Dates of Membership, and Involvement *
 
Personal Perspectives (* indicates Required Field)
Why do you wish to become a member of the Greater Des Moines Leadership Institute class? *
 
How have you exhibited, or how do you intend to exhibit, leadership skills on an issue, problem or challenge in the Greater Des Moines area? *
 
Voluntary Information
Successful applicants for the Greater Des Moines Leadership Institute class will be selected without regard to race, color, religion, sex, national origin, age, or disability. In order to assist the Class Selection Committee in achieving its goal of selecting a diverse class, we invite you to complete the voluntary age range, race/ethnic group and gender information.

Your participation in this matter is strictly voluntary and will remain confidential. Fields in this section are not required.
Age Range



Race/Ethnic Group





Gender

Tuition and Attendance Commitment
By submitting this application, I agree that if selected to participate in the Greater Des Moines Leadership Institute, I (my company or sponsoring organization) agree to pay the tuition, which is non- refundable. Tuition of $1500 is due by September 1, 2008.

The success of the Leadership Institute experience depends upon the active participation of all class members. The curriculum consists of bi-monthly Thursday afternoon meetings with dinner following, and four mandatory all-day Friday sessions. Any prospective member who is unable to attend the September orientation will not be allowed to continue in the program.

Class participants are expected to attend all of the sessions. Anyone missing more than three sessions will not be allowed to graduate with the class. A limited number of designated make-up sessions will be made available. You may be removed from the class without tuition reimbursement at the Board of Governor's discretion for not complying with the attendance policy.

TWO LETTERS OF RECOMMENDATION MUST ALSO BE SENT BY THE APPLICATION DEADLINE. LETTERS OF NOMINATION CAN BE USED WHERE APPROPRIATE. SEND LETTERS TO:

Class Selection Committee
Greater Des Moines Leadership Institute
700 Locust Street, Suite 100
Des Moines, IA 50309


Please list the names of two references, and their respective businesses/organizations, who will be sending letters of recommendation on your behalf. This information is required. *
Name and Business/Organization of Reference #1 *
 
Name and Business/Organization of Reference #2 *
 
Agree To The Terms Above (Required for consideration of application)
I understand and agree to abide by the financial commitment and attendance requirements stated above
Please check to make sure you have completed all required fields before you submit this form. We will send you an email within 2 business days confirming receipt of your application. If you do not hear from us by email within 2 business days, please call us at 515-286-4980 to confirm receipt of your application.
Application Information
***To be considered for the upcoming class, please pay a non-refundable application fee of $25.

If the applicant is applying for a second time or more, NO application fee is due. If applicant is not selected, the application fee is non-refundable***
Selection will be made on the basis of individual merit, with strong consideration Selection will be made on the basis of individual merit, with strong consideration Selection will be made on the basis of individual merit, with strong consideration given to the extent of community involvement, level and progression of career path, the content of the required two letters of recommendation, and composition of the class. Please answer each question completely, keeping in mind that selection is based on the information contained in this application. All applications are subject to confidential evaluation. Since the program has a limited number of participants, those not selected are strongly encouraged to apply in a subsequent year.



Name on the Card:
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Expiration Date: /
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Total:
$25.00