EMERGING LEADERS Fellowship & Internship (ELFI) Program

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

Date

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* 3. ADDRESS

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. ETHNICITY

AMERICAN INDIAN OR ALASKAN NATIVE

ASIAN OR PACIFIC ISLAND

AFRICAN-AMERICAN/BLACK

CAUCASIAN/WHITE

HISPANIC

NON-HISPANIC

OTHER

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* 5. GENDER

MALE

FEMALE

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* 6. DATE OF BIRTH

Date / Time

Date

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* 7. HIGHEST LEVEL OF EDUCATION

CURRENTLY IN HIGH SCHOOL

SOME HIGH SCHOOL

HIGH SCHOOL DIPLOMA

GENERAL EDUCATION DIPLOMA (GED)

TECHNICAL DEGREE/CERTIFICATION

SOME COLLEGE

COLLEGE DEGREE

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* 8. ARE YOU CURRENTLY EMPLOYED?

Yes

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

FULL-TIME

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?

YES

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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?

Yes

PLEASE COMPLETE IF YOU OWN A BUSINESS

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* 18. CURRENT EARNINGS?

WEEKLY

MONTHLY

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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