2021 Leadership Venango Application

Applications are due by August 14, 2020.

Acceptance notification will occur on or before September 4, 2020.

With the uncertainty around gatherings, we are accepting applications of interest, due to the Chamber by August 14th. In consideration of host locations, speakers and the comfort of class participants, the schedule and frequency of sessions will be determined by the end of August. Our goal is to provide the highest level of leadership development, likely with acombination of virtual and in person meetings, convened between September 2020 and May 2021.

Participant Contact Information

Name *

Name Preferred for Name Tag *

Employer/Organization *

Business Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Work Phone

Cell Phone

Email Address *

Home Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Years Living or Working in Venango County *

0 - 11 mo. 1 - 4 yr. 5 - 9 yr. 10+ yr.

Education Background

School Name

City, State

Major

Degree

List any additional college(s), business, trade schools, or other specialized training

Employment

Account for all periods, including military duty.

Present Employer *

Current Title/Responsibility *

Date Began

Time in Position *

List previous employers, including title/responsibility, and time in position.

Professional and/or Personal Achievements *

Your highest achievements, responsibilities, or skills to date

Community Involvement *

Please list, in order of importance, up to four community, civic, professional, business, religious, social, athletic, and other organizations of which you are or have been a member. Please include: Organization Name • Position Held • Dates

Briefly explain your interest in Leadership Venango and what you hope to gain from your participation. *

References

Name - Reference 1 *

Phone - Reference 1

Relationship - Reference 1 *

Name - Reference 2 *

Phone - Reference 2

Relationship - Reference 2 *

Candidate and Sponsor/Employer Agreement

I agree to the participant requirements of Leadership Venango, including attendance at all sessions and participation.

Please type your name here to indicate your agreement to these terms *

We will contact your employer to confirm approval for your participation in the class and the financial commitment.

Employer Name *

Employer Title *

Employer Phone

Employer Email *