Application

"*" indicates required fields

Application Code*

Please enter the application code received in the email from Leadership Georgia informing you of your nomination.

First Name (for your name badge, if selected)*

Last Name*

Full Name, including any prefixes or suffixes*

Current Employer*

Current Title*

Occupation Category*

What are your responsibilities in your current occupation?*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Residential County*

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Best Email*

Cell Phone*

Business Phone

Date of Birth*

Gender*

Ethnicity*

Years Lived in Georgia*

Years since last move to Georgia, if different

First Time Applicant*

Yes

If not, enter prior years applied

Current Status*

Spouse/Guest Name (Enter N/A if not applicable)*

Spouse/Guest Current Employer

Spouse/Guest Current Title

Spouse/Guest Residential Address (if different)

Best Spouse/Guest Email

Spouse/Guest Cell Phone

Spouse/Guest Date of Birth

Spouse/Guest Gender

Spouse/Guest Race

What do you hope to gain from participating in Leadership Georgia? (150 words max)*

What do you feel you can contribute to Leadership Georgia? (150 words max)*

List three challenges facing your community or the State of Georgia. Choose one and describe what role, if any, you expect to play in helping address this challenge? (150 words max)*

Please share about a time when your perspective has been broadened or changed. (150 words max)*

What are the driving forces or motivations that have led to your greatest achievements? (150 words max)*

Explain your involvement in 3 community activities - civic, business, religious, political or social in nature: indicate name of the organization, describe your responsibilities and roles.

Community Involvement Activity 1.*

Community Involvement Activity 2.*

Community Involvement Activity 3.*

List previous three employments (if applicable) and titles, and describe job duties at each.*

List up to three professional affiliations, organizations or associations you are involved with, along with leadership roles and years involved.

Education: Please include degree awarded and year received, along with name and location or institutions, if applicable. (High School, Undergraduate, Advanced Degrees)*

List significant continuing education experiences.*

List significant activities, awards, offices held.*

Please list names of up to three people who will write letters of recommendation for you. Please share this link: https://leadershipgeorgia.com/lor/ so they can submit letters. They will need your Application Code. You are strongly encouraged to have 3, but no more than 3, letters.

Please share this link with people writing your letters of recommendation. They will need your Application Code. Submit a Letter of Recommendation

Would you approve of Leadership Georgia announcing your selection?

If yes, provide name and contact information for your local newspaper

Attending all 5 program weekends is mandatory for you and your spouse/guest. If selected, will you commit to all 5 programs?*

Is your spouse/guest able to commit to all 5 programs?

Headshot Image (at least 800x800)*

Accepted file types: jpg, png, bmp, jpeg, Max. file size: 30 MB.