Applications are due by August 6, 2021. Acceptance notification will occur on or before September 3, 2021. Participant Contact Information Name * Name Preferred for Name Tag * Employer/Organization * Business Address Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DC Zip/Postal Code * Work Phone Cell Phone Email Address * Home Address Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DC 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 *