[TYPE THE COMPANY NAME]

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Program Application

September 2015-June 2016

Celebrating 30 Years of Service to the Community!

Empowering Communities One Leader at a Time

THE PROGRAM Leadership Prince George’s Inc. (LPG) is dedicated to developing Leaders and Community Trustees. Graduation from LPG requires the completion of a ten month program, which includes an overnight Opening and Closing Retreat, and eight Program Days. The Program culminates with a Graduation and Leadership Recognition Dinner. During the program year, participants receive extensive leadership training, professional development, and have access to valuable networking opportunities with public and private stakeholders. In addition, class members discuss current issues and participate in activities designed to enhance their understanding of Prince George’s County and the Region.

SELECTION OF PARTICIPANTS

Participation is open to leaders twenty-five years of age and older. LPG seeks participants of diverse ages, genders, ethnic backgrounds, professional experiences, and interests.

PROGRAM TIMEFRAME

WELCOME RECEPTION September 2, 2015 OPENING RETREAT September 9-11, 2015 COUNTY TOUR October 14, 2015 LEADERSHIP TRAINING & PROFESSIONAL DEV. November 18, 2015* ECONOMIC DEVELOPMENT December 9, 2015 HEALTH AND HUMAN SERVICES January 20, 2016* DAY IN ANNAPOLIS February 10, 2016 PUBLIC SAFETY March 9, 2016 EDUCATION April 13, 2016 ARTS & CULTURE May 11, 2016 CLOSING RETREAT June 1-3, 2016 GRADUATION June 15, 2016

*3rd Wednesday Participation is mandatory at overnight Opening and Closing Retreats and each monthly Program Day. ALLOWANCE IS MADE FOR A MAXIMUM OF TWELVE HOURS DURING THE PROGRAM YEAR

ONLY (OCTOBER TO MAY). THE TWELVE HOURS “ABSENCE ALLOWANCE” DOES NOT APPLY TO THE OPENING RETREAT.

PROGRAM TUITION

The LPG program fee is $4,000.00 per person which includes the 2016-2017 Membership Fee. Full tuition must be paid by July 31, 2015 by credit card, check, money order made payable to Leadership Prince George’s, Inc.

Please note that the application deadline for the

September 2015 to June 2016 program is June 26, 2015. Only Typed Applications Are Accepted.

PREFERRED CONTACT HOME WORK

Name: ___________________________________________________________________________________

Home Address: ____________________________________________________________________________

City: _________________________ State: __________________ Zip: __________________

Home Phone: _____________________________ Cell Phone: _____________________________

Personal E-mail Address: _____________________________________________________________________

Number of years living/working in Prince George’s County? (L) ________ (W) ________

Age: ___ 25- 30 ___ 31–45 ___ 46–60 ___ over 60 Female ______ Male _______

Leadership Prince George’s seeks to reflect racial, cultural, and ethnic diversity in our membership. Please mark the racial/ethnic category (ies) with which you identify (optional):

African American Asian/Pacific Islander Caucasian

Hispanic/Latino Native Other:

How Did You Hear About Leadership Prince George’s? _______________________________________

POST SECONDARY EDUCATION

Degree Institution Location

CONFIDENTIAL APPLICATION

Personal Data

Leadership Prince George’s P.O. Box 6407

Largo, MD 20774 1-844-821-9359

leadershipprincegeorges@gmail.com www.leadershipprincegeorges.com

Please attach a resume that includes education and employment.

Current Employer/Position: ______________________________________________________________________

Title: ______________________________________ Years with Employer in Position: ______________________

Work Address: ________________________________________________________________________________

City: _________________________ State: ___________________ Zip: ________________________

Business Phone: ______________________________________________________________________

Business E-mail Address: _____________________________________________________________

Type of Organization (Check One) ___Business Non-Profit ___Government ___Academia

Media ____ Self Employed ___Other (please describe) ____________

Briefly Describe Your Company/Organization and Professional Responsibilities:

________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Please List up to Seven Community, Civic, Professional, Business, Religious, Social, Athletic or Other Organizations in Which you Have Been Involved:

Organization Dates of Membership Position(s)

List Awards and Honors You Have Received as Well as Significant Activities You Have Participated In.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Community Involvement

Professional

Honors, Awards, Activities

(Limit each response to 150 words)

Describe One Example of Where You Have Gone Beyond Conventional Thinking to Identify New Opportunities, Seek Fundamental Change, or Achieve Something Outstanding.

Describe the Community Concern/Issue in Prince George’s County that is Most Important to You – Include Personal Experience and/or Impact of Concern/Issue on the Community.

Program Statements

STATEMENT OF APPLICANT COMMITMENT

I have reviewed and fully understand the requirements to participate in the LPG Program. I agree to the terms and conditions outlined in the application information. I understand that if selected, the full tuition of $4,000.00 must be paid by July 31, 2015. If I do not comply with the tuition requirements, I understand that I may be dropped from the Program and, if necessary, collection efforts will be initiated against me and/or my sponsoring organization. If Leadership Prince George’s is unable to obtain the tuition after several collection attempts, I understand that I am held liable for payment to Leadership Prince George’s in the amount of $4,000.00.

I have reviewed the Program timeframe and the Attendance Policy, and commit to attending the required Opening and Closing retreats and all programs and sessions as scheduled. I fully understand that I am subject to the attendance policy and I am aware of the penalties for non-attendance. I understand and acknowledge that once I am accepted, my tuition is non-refundable; and, if I am dismissed from the Program or if I voluntarily withdraw for any reason, I forfeit my entire tuition payment.

I understand that Leadership Prince George’s expects that upon my graduation, I will remain actively involved and supportive of LPG’s committees and activities, and will annually update my contact information and pay my annual membership dues.

Signature (Applicant) __________________________________ Date _______________ (required)

SPONSORS/APPLICANT (If applicant is paying personally, applicant must sign sponsor line below.)

As the Applicant’s Sponsor, the Applicant has my full support in their participation in the Leadership Prince George’s program. I understand and fully support the Leadership Prince George’s attendance policy and tuition payment requirements for the above signed Applicant. If tuition is not paid by July 31, 2015, I understand that the above signed applicant may be dropped from the program and if necessary, collection efforts will be initiated against the sponsoring organization and/or the Applicant.

Signature (Sponsor/Applicant) ________________________________ Date_____________ (required)

Applicant / Sponsor Commitment Form

RESUME & BIOGRAPHY Please attach a copy of your most updated resume and a 150 word biography to the application packet. RECOMMENDATION LETTERS Please provide two Letters of Recommendation from individuals who can cite specific examples of your community and/or professional leadership and involvement. Please attach both letters to your application. Additional letters beyond the two required will be discarded. APPLICANT/SPONSOR COMMITMENT FORM Please attach a signed Applicant/Sponsor Commitment form to the application packet. If the applicant is self-employed and/or will not have a sponsor, the applicant is required to sign both the applicant and sponsor sections of the form.

COMPLETED APPLICATION A completed application packet must be received by 5:00 p.m. on Friday, June 26, 2015. Mail the completed application packet to: Leadership Prince George’s, Inc., P O Box 6407 Largo, MD 20774 No application packet or materials received via fax will be processed. Before you submit your application packet, please ensure that you have the following:

Application Two Personal Statements Resume Biography (150 words) Two Recommendation Letters Applicant/Sponsor Commitment Form

If a significant change occurs that affects your ability to participate in the program (i.e., change of employment status, residency, etc.), please notify LPG immediately.