2013 APPLICATION FORM
Leadership Northwest is a dynamic leadership development training course for current and emerging community leaders.
The course includes nine months of intensive training (one day-long session each month), which focuses on leadership
development and knowledge of the community. To be considered for the program, please complete this application.
1. Download the Application Form. Once the form is completed, save the form to your computer, and email it to
bpayne@nwtcc.org with a digital photograph of yourself.
2. Remit application fee (if applicable) by check. (No application fee if received by July 19, 2013. $50 application
fee if received on or after August 16)
3. Print the Class Calendar and retain for your records. You may want to pencil the Class dates in your calendar.
Your application, application fee, photo and recommendation form must be received by Leadership Northwest no later
than Friday, August 16, 2013. Incomplete or late applications may not be considered. Do not remit tuition payment with
your application. The 2013-2014 Leadership Northwest class will be announced the week of August 26, 2013.
The Selection Committee (Leadership NW Board) is looking for applicants who:
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Have been involved in volunteerism and want to strengthen leadership practices to enhance their potential.
Serve in a leadership capacity in organizations related to their profession, academic institution or other young
professional organizations.
Typically, they are considered rising stars in business, government, non-profit, the service sector or as an
entrepreneur.
Aspire to become actively engaged in Northwest Tarrant County through decision making roles on community
boards and city commissions.
Possess high standards of personal quality and integrity.
Can and will commit the time required for the program.
If employed, have the endorsement of their employer or indication the employer does not object to their taking
time off from work for Leadership Northwest activities.
PARTICIPATION IS A TWO-YEAR COMMITMENT!
Leadership Northwest is designed to be a learning experience. Therefore, it requires the following commitments on the
part of those who participate:
1. Attendance at the Retreat in September.
2. Attendance at the eight monthly classes and a limited number of outside hours. See attached schedule. Note:
Dates and times are tentative and may be altered. Significant notice will be given to attendees regarding
changes.
3. Anyone absent from more than twelve (12) hours of Class Days will not receive a certificate of completion.
4. No refunds will be made after the first class in September.
5. Employers must agree to give participants leave time for scheduled sessions.
6. Applicants agree to refrain from running for public office during the course of Leadership
Northwest unless they withdraw from the class.
2013 APPLICATION FORM
LEADERSHIP NORTHWEST
CLASS OF 2013-2014
For Office Use Only
Application received on: _____________
EARLY BIRD DEADLINE FOR APPLICATION:
Friday, July 19, 2013 – No Application Fee
FINAL DEADLINE FOR APPLICATION:
Friday, August 16, 2013 – Fee $50
Application Fee: ___________________
Photograph: _______________________
CONSIDERATION FOR SCHOLARSHIP REQUESTED
See the last page of the application form for information.
YES
NO (double click to CHECK)
Recommendation: __________________
PLEASE TYPE:
Name:
Last
First
Middle
Company:
Current Position
Business Address:
Business Phone
No. of Employees
Mailing Address
City
FAX
Email Address
State
Profit
Type of Business
Home Address:
Mailing Address
Home Phone
Date of Birth
Nickname
City
Cell Phone
Month
Ethnic Background:
(double click to check)
/
Day
/
Year
Anglo
Asian
Zip
Non-Profit
State
Zip
Spouse
Male
Female (double click to check)
African-American
Hispanic/Latino
Native American
Multi-racial
2013 APPLICATION FORM
Describe Your Position and Responsibilities At Your Current Employer:
Tell Us About Your Community Involvement:
List any community, civic, professional, educational and religious organizations in which you have been involved. (If you
have recently moved to the area, please list activities in which you were involved in your previous community.)
Organization:
Dates/# hrs per month:
Nature of Participation:
What is one issue facing Northwest Tarrant that you, personally, are concerned about? How would you use your
leadership training to benefit the community?
Why do you want to participate in Leadership Northwest? What specific skills/knowledge do you hope to gain?
I
do have the full support of my employer for the time required to participate in Leadership Northwest.
Tuition for the program is $450, payable by September 5, 2013.
Send statement for $450 tuition to: (Check one and provide name and mailing address.)
Company
Organization
Send Invoice to (address):
Applicant
Other
Information on Scholarships
Limited scholarships are available. All applicants are responsible for at least $225. Partial scholarships are awarded
solely on the basis of documented financial need and availability of tuition scholarship dollars. Proof of financial need may
be requested. Scholarship amount requested: $
2013 APPLICATION FORM
If you are requesting a scholarship, please explain the circumstances.
It is my understanding that Leadership Northwest is a learning experience and requires attendance at each session.
The Opening Retreat, which is mandatory, will be September 12, 2013. Subsequent Class Days will be held from
8:30am – 5:00 pm on the 2nd Thursday of each month from October - May. Any participant missing any part of The
Opening Retreat or more than twelve (12) hours of the Class Days will not graduate.
Leadership Northwest Calendar
DATES
September 10, 2013
DAY
Tuesday
EVENT
Alumni/New Class Get Acquainted
Reception
Opening Retreat
TIME
6:00 p.m. – 7:30 p.m.
HOURS
1.5
*September 12,
Thursday
8:00 a m - 5:00 p m
9
2013
October 10, 2013
Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
November 14, 2013 Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
December 12, 2013 Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
January 9, 2014
Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
February 13, 2014
Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
March 13, 2014
Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
April 10, 2014
Thursday
Class Day
8:30 p.m. – 5:00 p.m.
8.5
May 8, 2014
Thursday
Class Day
8:30 a.m. – 5:00 p.m.
8.5
*June 12, 2014
Thursday
Graduation
TBA
(*) Denotes a mandatory meeting--all participants must attend its entirety in order to graduate.
I hereby give Leadership Northwest the right to make inquiries regarding the information provided on this application and
have my employers consent to fully participate in this program.
Signature
Date
Employers Signature
Date
The size and composition of each Leadership Northwest class is carefully considered to ensure that it is broad based, representing a
variety of professional, economic, social, and ethnic backgrounds. Consequently, many highly qualified applicants may not be
accepted the first time they apply. We encourage you to re-apply should you not be accepted this year.
Your application, application fee (if application is received on or after August 16, 2013), and photo must be received by
Leadership Northwest no later than Friday, August 16, 2013.
All Leadership Northwest application materials should be submitted by email to bpayne@nwtcc.org or via U.S.
mail to: Leadership Northwest, 3918 Telephone Road, Ste. 300, Lake Worth, TX 76135