Class XXXIX Application

*Submission of your application will not be possible until all questions have been answered and all documents are attached. If you do not see a confirmation of your successful submission on the screen after you hit the submit button, scroll through the application to identify incomplete questions.

First Name (Please DO NOT use all caps) * If chosen to participate in the class, this is exactly how you would want your classmates to refer to you. It is also the name that would appear on your nametag and ALL documentation, if chosen to participate in the program.

Middle Initial

Race Optional

Birth Date * Use format MM/DD/YYYY

Last Name (Please DO NOT use all caps) * If chosen to participate in the class, this is how you would want your classmates to refer to you. It is also the name that would appear on your nametag and ALL documentation, if chosen to participate in the program.

Age

Gender *

Male
Female

Employer (or the organization sponsoring you & paying your tuition.) *

Job Title *

Work Address *

City *

State *

Zip Code *

Work Phone * (Please use this format XXX-XXX-XXXX)

Cell Phone * *If you are selected, your cell number will be listed on the class roster (for class members only).

Home Phone * (Please use this format XXX-XXX-XXXX)

Email Address * Please list the email that you want to use as your primary communication throughout the application process as well as during the class, if selected to participate.

Home Address *

City *

State *

Zip Code *

Have you lived in Pulaski County for the last 12 months? *

YES
NO

If you answered NO you have not lived in Pulaski County for the last 12 months, provide an explanation here.

Have you worked in Pulaski County for the last 12 months? *

YES
NO

If you answered NO you have not worked in Pulaski County for the last 12 months, provide an explanation here.

Place of Birth City *

Place of Birth State *

Emergency Contact Name *

Spouse's Name (if Applicable)

Emergency Contact Number *

Leisure Activities *

One unusual or “fun” fact about yourself * Please do not list something you would not want to be shared with classmates, if chosen to participate in Class XXXIX. Make it FUN!

Have you participated in Leadership programs in other cities? *

Yes
No

If yes, which cities?

Have you previously applied to Leadership Greater Little Rock? *

Yes
No

If yes, in what year(s)?

Employment (since graduation from high school or college through current; please include employment responsibilities) *

Business/Professional Affiliations (include professional/trade associates or other professional activities) *

Civic/Community/Volunteer Affiliations (may include civic, religious, political, government, social, athletic or other activities) *

Special Awards or Honors (include career or civic/community awards) *

Education (include high school, college and post graduate) *

What leadership qualities do you possess and how have you used them? * 300 words or less

What leadership qualities do you hope to strengthen or acquire? * 300 words or less

What do you believe are the two most significant issues or problems facing the Metro Little Rock area at this time? What action would you suggest to address one of these issues or problems? * 500 words or less

Briefly describe any volunteer/community service involvement. You will be asked to go into more detail during your one-on-one interview. * 300 words or less

Why do you want to participate in the LGLR program and what do you expect to gain from it? * 300 words or less

TUITION

If accepted into the LGLR program, the tuition fee of $2,500 MUST be paid in full by Wednesday, September 20, 2023, to participate in the program. Who will pay the tuition fee? *

My employer will pay the tuition fee.
I will pay the tuition fee personally.
Other

Financial Assistance

Are you requesting a scholarship to participate in the program? * A limited number of scholarships are available. Scholarships are considered on a case-by-case basis.

Yes
No

If you answered YES, please explain (in detail) why you are requesting a scholarship. Please provide ALL information that you would like the selection committee to consider when reviewing your scholarship requests. Examples of information to include...Will you be able to participate if a scholarship is not provided? Could you pay a portion of the tuition?

Signed Participant Commitment Form * Download the form from the link provided on this page above the application

Signed Employer Commitment Form * Download the form from the link provided on this page above the application

Head Shot * Please upload a head shot. This DOES NOT have to be a professional photo.

First Letter of Recommendation * Please submit a letter of recommendation from an EMPLOYER or CO-WORKER who can speak to your ability to meet selection criteria. *Do not submit application until both letters are attached. Applications without completed letters will not be considered.

First Letter From * Employer or coworker's name

Second Letter of Recommendation * Please submit a letter of recommendation from a NON-WORK-RELATED source who can speak to your ability to meet selection criteria. *Do not submit application until both letters are attached. Applications without completed letters will not be considered.

Second Letter From * Non-work-related source's name