First Name

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* 1. First Name

Last Name

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* 2. Last Name

Phone Number

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* 3. Phone Number

Street address

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* 4. Street address

City

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* 5. City

State

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* 6. State

Zip Code

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* 7. Zip Code

Email

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* 8. Email

Will you be able to fulfill this commitment?

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* 9. Will you be able to fulfill this commitment?

Is your employer aware of your application?

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* 10. Is your employer aware of your application?

If applicable, has your employer authorized the required time commitment for participation in Leadership Walton?

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* 11. If applicable, has your employer authorized the required time commitment for participation in Leadership Walton?

Current Employer

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* 12. Current Employer

Business Address

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* 13. Business Address

Business Phone

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* 14. Business Phone

Current Title/Position

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* 15. Current Title/Position

Type of Business

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* 16. Type of Business

Date of Hire

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* 17. Date of Hire

Years in this position

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* 18. Years in this position

Website

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* 19. Website

Briefly describe your responsibilities

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* 20. Briefly describe your responsibilities

Previous Employer

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* 21. Previous Employer

Title/Responsibility

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* 22. Title/Responsibility

Dates Employed

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* 23. Dates Employed

Previous Employer

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* 24. Previous Employer

Title/Responsibility

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* 25. Title/Responsibility

Dates Employed

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* 26. Dates Employed

What do you consider your highest responsibility, skill or career achievement so far?

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* 27. What do you consider your highest responsibility, skill or career achievement so far?

What Organizations/Activities/Community Involvement have you participated in? List dates and positions held in each.

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* 28. What Organizations/Activities/Community Involvement have you participated in? List dates and positions held in each.

What do you consider to have been a highlight or major accomplishment associated with any of the groups/ activities mentioned?

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* 29. What do you consider to have been a highlight or major accomplishment associated with any of the groups/ activities mentioned?

Did You Receive Awards or Honors? Please describe.

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* 30. Did You Receive Awards or Honors? Please describe.

Please list, in order of importance to you, up to three civic, business, religious, social, athletic, or community organizations not listed above in which you have been involved.

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* 31. Please list, in order of importance to you, up to three civic, business, religious, social, athletic, or community organizations not listed above in which you have been involved.

What do you expect to gain from your participation in Leadership Walton?

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* 32. What do you expect to gain from your participation in Leadership Walton?

Describe what you consider to be the three most pressing issues facing the Walton Area.

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* 33. Describe what you consider to be the three most pressing issues facing the Walton Area.

What do you feel are the three biggest opportunities for the Walton Area?

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* 34. What do you feel are the three biggest opportunities for the Walton Area?

Henry David Thoreau said, “Things do not change, we change”. How do you expect to change as a result of the Leadership Walton experience and how would you like to see the Greater Walton Area change?

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* 35. Henry David Thoreau said, “Things do not change, we change”. How do you expect to change as a result of the Leadership Walton experience and how would you like to see the Greater Walton Area change?

Tuition includes all course materials, assessments, supplies and refreshments and is $1,375 for employees of Walton Area Chamber members, or $1,675 for non-Chamber members. Tuition must be received by the Walton Area Chamber by September 15, 2017. Will you, your company, or a combination make the payment of the tuition fee?

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* 36. Tuition includes all course materials, assessments, supplies and refreshments and is $1,375 for employees of Walton Area Chamber members, or $1,675 for non-Chamber members. Tuition must be received by the Walton Area Chamber by September 15, 2017. Will you, your company, or a combination make the payment of the tuition fee?

STATEMENT OF UNDERSTANDING I understand the purpose of Leadership Walton and if I am selected for the 2017-2018 class, I will devote the time and resources necessary to complete the program. I understand that there is an attendance requirement and if more than one (1) program sessions are missed regardless of the reason, that I may be dropped from the program and that no portion of the tuition will be returned. I also understand that I will be required to attend the mandatory two-day, overnight retreat in late September 2017 (DATE TBD) and a two-day trip to Tallahassee for the 2018 Legislative Session. Discounted room rates will be available at my expense for the Tallahassee trip. I also understand that I must participate in a mandatory conference call two weeks prior to the Leadership Walton retreat in September 2017. In addition, I’m to schedule at least monthly meetings with my mentor to complete the program. I understand that completion of this application does not guarantee a candidate’s acceptance into the 2017-2018 class. All applicants will be notified if their application does not meet the requirements. Please type your full name if you agree to the statement of understanding.

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* 37. STATEMENT OF UNDERSTANDING I understand the purpose of Leadership Walton and if I am selected for the 2017-2018 class, I will devote the time and resources necessary to complete the program. I understand that there is an attendance requirement and if more than one (1) program sessions are missed regardless of the reason, that I may be dropped from the program and that no portion of the tuition will be returned. I also understand that I will be required to attend the mandatory two-day, overnight retreat in late September 2017 (DATE TBD) and a two-day trip to Tallahassee for the 2018 Legislative Session. Discounted room rates will be available at my expense for the Tallahassee trip. I also understand that I must participate in a mandatory conference call two weeks prior to the Leadership Walton retreat in September 2017. In addition, I’m to schedule at least monthly meetings with my mentor to complete the program. I understand that completion of this application does not guarantee a candidate’s acceptance into the 2017-2018 class. All applicants will be notified if their application does not meet the requirements. Please type your full name if you agree to the statement of understanding.

Date

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* 38. Date

Date / Time
Employer Commitment (If applicable) This application has the approval of this organization and the applicant has our full support which includes time to participate. I understand that there is an attendance requirement and if more than one (1) program session is missed regardless of the reason, that my representative may be dropped from the program and that no portion of the tuition will be returned. Please type name of organization.

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* 39. Employer Commitment (If applicable) This application has the approval of this organization and the applicant has our full support which includes time to participate. I understand that there is an attendance requirement and if more than one (1) program session is missed regardless of the reason, that my representative may be dropped from the program and that no portion of the tuition will be returned. Please type name of organization.

Representative and Title

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* 40. Representative and Title

Date

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* 41. Date

Date / Time

T