This form must be typed or printed in black ink. Please fill out as completely as possible but limit answers to the space provided. A $50 deposit is required with the application. The deposit will be applied to tuition or refunded if not selected. Applications due: August 14, 2015.
1. Personal Information
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Last Name First Middle Preferred Name
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Home Address City ST ZIP
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Employer (if applicable) Position
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Employer’s Address City ST ZIP
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Phone Number Fax Number
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Briefly describe job responsibilities if you are employed, or your chief activities if you are not employed.
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How long have you lived or worked in Haywood County?_______________________________________
Spouse’s name (if applicable)______________________________________________________________
Children (names and ages)
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2. Organizations and Activities
Please list, in order of importance, up to five community, political, professional, civic, business, religious, social, athletic or other organizations in which you have been involved.
Activity/Organization Date Responsibilities
What have you accomplished in these activities that you think is important?
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Other interests/or hobbies_________________________________________________________________
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Interesting facts about you_______________________________________________________________
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3. Education
Please outline your academic background, training and continuing education experiences.
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List your extracurricular activities and special honors awarded for leadership activities.
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4. Participation
In order to accomplish our objectives, the full participation of each individual selected is necessary. Will you be able to fulfill such a commitment? ____________________________________________________
Do you have the support of your employer for the time required to participate in the Leadership Haywood
County experience? _____________________________________________________________________
Attendance is mandatory for Leadership Orientation. You are allowed to miss *two* class sessions – your third absence will disqualify you from graduation – no exceptions. Partial day attendance counts as an absence.
All class sessions last a full day. Leadership Orientation is an overnight stay at Our Lady Queen of Peace
Retreat Center in Dancyville, Tennessee. Your tuition includes the cost of all meals, transportation, and class supplies.
An Agenda of Sessions (with Tentative Dates):
Leadership Orientation - September 17&18, 2015-Our Lady Queen of Peace, Dancyville, TN
Economic Development and Agriculture - October 8, 2015
Quality of Life - October 29, 2015
Public Safety and Justice - November 19, 2015
Local Government and Infrastructure - December 10, 2015
Healthcare and Social Services - January 14, 2016
Educational Issues facing Haywood County - February 11, 2016
Vision - March 17, 2016
State Government – Day-trip to Nashville - date TBD
Graduation - April 21, 2016
All students must attend at least one session of each of the following community board meetings:
City of Brownsville or Stanton City Board, Board of Education, and Haywood County Commission; therefore, a total of attending three meetings is required.

5. Community Analysis
Please identify a particular challenge, issue, or problem you feel is critical to Haywood County. Explain your concerns and possible involvement in the solution.
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In your opinion, in what areas is Haywood County strong?
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6. References- Please list the name, address and phone number of two references that know you.
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7. Tuition
Tuition for Leadership Haywood County is $ 400.00
. Upon acceptance to the program, tuition must be paid in full no later than September 1st.
I understand the financial and attendance requirements to participate in Leadership Haywood County, and agree to abide by them if selected to participate as a class member.
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Signature
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Date
Mail or take form to: Brownsville-Haywood County Chamber of Commerce
121 West Main Street
Brownsville, TN 38012