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* 1. Full Name

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* 2. Address Where You Are Registered to Vote

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* 3. Length of time you have lived at the above address:

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* 4. Date of Birth

Date

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* 5. Phone Number

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* 6. Email Address

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* 7. Job Title/Occupation

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* 8. Employer or Organization Name

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* 9. Registered Political Affiliation

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* 10. What area of public leadership interests you most?

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* 11. The Public Leadership Institute is a program for aspiring public leaders with a background in business and leadership in community. Please make the case for why you should be admitted to PLI and why your background makes you a good candidate:

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* 12. Please describe what you view as the most important public policy issues in the region, and how your experience could be used to address these issues:

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* 13. What is your time table for exploring candidacy or an appointment to a board or commission? 

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* 14. What specifically do you hope to learn in this program?

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* 15. If you have ever run for office or worked/volunteered as a staff member on a campaign, please list them below.

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* 16. Please list any particular offices or boards and commissions you are interested in pursuing: 

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* 17. How did you hear about PLI?

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* 18. Please list two references and include their title and their phone number:

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* 19. Upload your resume

PDF, DOC, DOCX file types only.
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* 20. If there is any other information you would like to share with the selection committee, particularly as it demonstrates your commitment to public service, community engagement, and leadership, please do so below. Note: admittance into PLI does not guarantee a future candidate endorsement or support from program sponsors.

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