PARTNERSHIP WITH THE CITY OF ST. PETE, ONE COMMUNITY & CDAT
APPLICATION DEADLINE OCTOBER 21, 2018

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* 1. NAME

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* 2. TODAY'S DATE

Date / Time

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* 3. ADDRESS

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* 4. ETHNICITY

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* 5. GENDER

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* 6. DATE OF BIRTH

Date / Time

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* 7. HIGHEST LEVEL OF EDUCATION

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* 8. ARE YOU CURRENTLY EMPLOYED?

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* 9. IF SO, FULL-TIME OR PART-TIME?

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* 10. AVERAGE HOURS PER WEEK WORKED IN THE PAST 12 MONTHS?

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* 11. JOB TITLE?

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* 12. ARE YOU THE HEAD OF HOUSEHOLD?

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* 13. WHAT IS YOUR HOUSEHOLD SIZE?

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* 14. WHAT IS THE COMBINED HOUSEHOLD INCOME?  $

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* 15. PLEASE LIST CURRENT COMMUNITY VOLUNTEER AND/OR LEADERSHIP ROLES.

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* 16. WHY ARE YOU INTERESTED IN THE PROGRAM?

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* 17. ARE YOU A U.S. CITIZEN?

PLEASE COMPLETE IF YOU OWN A BUSINESS

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* 18. CURRENT EARNINGS?

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* 19. BUSINESS NAME

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* 20. BUSINESS ADDRESS/CITY/STATE/ZIP

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* 21. PRODUCTS & SERVICES OFFERED

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* 22. HOW LONG HAVE YOU OWNED YOUR BUSINESS?

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* 23. HOW MANY PEOPLE WORK WITH YOU? (PARTNERS/STAFF)

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* 24. HOW DID YOU FIND OUT ABOUT THE PROGRAM?

FMI: PLEASE CONTACT 2020EMERGINGLEADERS@GMAIL.COM

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