Leadership Main Line

Application Form: Class of 2016

Business Contact Information

First Name:

MI:

Last Name:

Number of Years Working / Living in Main Line Area:

Business/Organization Name:

Member of Main Line Chamber?

Gold

Standard

Business Address:

City:

State:

Zip:

Work Phone #:

Work E-Mail:

Start Date:

Present Title:

Present Responsibilities:

Immediate Supervisor Information

Immediate Supervisor Full Name:

Immediate Supervisor Contact Info:

Personal Contact Information

Home Address:

City:

State:

Zip:

Home or Cell Phone #:

Personal E-Mail:

Any Potential Conflicts?

Barring unforseen developments, are you able to commit to attend all Leadership Main Line sessions?:

Yes

Please list conflicts:

Leadership Perspectives:

Please answer the following questions, limiting your answers to the space provided.

Identify and discuss one significant opportunity, challenge, or issue that you feel is critical to the Main Line area today.

Briefly explain what you hope to gain from your Leadership Main Line experience and how it will help fulfill your own personal and professional goals.

What key qualities do you feel you bring to the Leadership Main Line program?

What skills, knowledge and/or expertise would you like to gain, hone or improve through your participation in Leadership Main Line? (Please list 4)

What do you consider your most significant skill or career achievement thus far?

Organizations and Activities:

Please list, in order of importance to you, up to five community, civic, professional, business, religious, social, athletic or other organizations of which you have been a member in the Main Line area.

(Please list in following order: Organization, Your Title, Your Responsibilities, Dates of Membership)

List special awards or recognition for civic performance:

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

In your opinion, what is your potential as a community leader?

What do you consider your most significant skill or career achievement thus far?

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

Yes

If not, why not?:

Submit or Clear Form The information I have provided in this application is, to the best of my knowledge, correct. I understand that if any of the information above is found to be incorrect, my application will be denied.

By submitting this form I understand that this application is not complete until I have emailed my resume and two references have been submitted on my behalf.

Leadership Main Line

Application Form: Class of 2016

For questions or for details on sponsoring this program please contact the Chamber at: 610-687-6232.

Leadership Main Line | The Main Line Chamber of Commerce | 175 Strafford Ave, Suite 130 | Wayne, PA 19087