Leadership Birmingham

Leadership Birmingham
505 20th Street North, Suite 1125
Birmingham, AL 35203
252-4496/Fax 252-4497

**Confidential Application**
Autobiographical Outline and Questionaire
Applications are due back by May 1, 2009
(please fill out form and print)

First Name:

Middle Name:

Last Name:

Age: Sex: Race: Years in Birmingham:

Home Phone:

Home Address:

City:

St: Zip:

Business (Org):

Title:

Bus. Address:

Bus. Phone:

Fax:

Spouse's Name:

Ages of Children:

Email:

EDUCATION

(Begin with high school, then college(s), business or trade schools and/or other specialized training.)

Name and City/State of School	Dates (From-To)	Degree	Major

Extracurricular Activities and Special Honors or Awards for Leadership Activities (please indicate school):

Special Honors, Awards, Prizes for Academic Performance (please indicate school):

If you attended college, what percentage of your college expenses did you earn?

0-10%

10-25%

25-50%

50-75%

75-100%

From what sources was your education financed?

	Scholarship (service free)		Assistantship (service rendered)		Veterans' Benefits
	Part-time or Full-time jobs		Family, Relatives, or Friends		Other

FAMILY

Present or Past Occupation of:

Father:

Mother:

Number of Brothers:

Number of Sisters:

EMPLOYMENT

Present Employer:		Date Began:
Present Title of Responsibility:		Since (Date):

How many days per month does your work require you to be out of the city?

Because there will be more applications for Leadership Birmingham that there are spaces, we must ask that participants commit to attending at least 80% of Leadership Birmingham's course. Are you and/or your employer willing to make such a September-June time commitment?

Yes

Absenteeism will result in being dropped from the course. If you are unable to make a commitment, it is not in your best interest to apply at this time. Please Note: full attendance at the opening retreat and closing retreat is mandatory. Dates are Friday, September 11 and Saturday, September 12, 2009 and Friday, June 4 and Saturday, June 5, 2010.

Previous employment, in reverse chronological order, (account for all periods, including military active duty):

Employer	Title or Responsibility	From	To	Reason for Leaving

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

ORGANIZATION AND ACTIVITIES

(Please list, in order of importance to you, up to five community, civic, professional, business, religious, social, athletic and other organizations of which you have been a member.)

Organization	Approximate Dates of Membership	Official Positions Held and Date

What have you accomplished in these activities that you think is important?

How much time each month do you commit to community, civic, professional and other organizations and activities?

Have you been as active in community, civic, professional and other activities as you would like to be?

Yes

If not, what have been the major barriers to your becoming involved?

If you have previously not had the time or interest to become actively involved, what conditions have changed that now enable you to seek involvement in the community?

GENERAL

What do you hope to gain from your Leadership Birmingham experience?

To graduate from the Leadership Birmingham program, attendance at a minimum of 80% of the meetings is required. Please check program schedule under Year at a Glance to make sure you are able to attend the sessions.
What percentage of the meetings do you believe you will be able to attend?

100%

90-100%

80-90%

under 80%

What are your chief hobbies and recreational activities?

Are you a registered and active voter?

Yes

If accepted into the Leadership Birmingham program, you or your company will be billed for the tuition of $1,250, which covers all costs, including meals, unless you indicate that you wish to apply for a scholarship. Do you wish to apply for such a scholarship?

Yes

In your judgement, what are the three most pressing problems facing Birmingham and environs today? Explain why and discuss your recommendations for approaching and resolving these problems.