Leadership Lackawanna

Leadership Lackawanna is a ten-month program, running from September until June
Sessions are held one weekday each month, from 8:30am until 4:00pm.
The Selection Committee bases its decision on the information provided in the application; therefore complete every section and be as thorough as possible. Try to limit your answers to the space provided. If necessary, continue your responses on plain white paper and attach. The quality and appearance of the materials are taken into consideration.
The application must be signed by both the candidate and his/her employer/sponsoring organization. Only the candidate’s signature is required in the case of a self-proposed nomination/application. If the applicant does not have the support of his/her employer/sponsoring organization to participate in the program, please explain the reason(s) on a separate page.
Applications must be received at Leadership Lackawanna, 222 Mulberry Street, P.O. Box 431, Scranton, PA 18501-0431, by 4:30 PM, April 30, 2010. Applicants will be notified in early June.
A non-refundable $25 processing fee (payable to Leadership Lackawanna) must accompany the application. A deposit payment of $100 is required upon acceptance into the program. The remaining tuition balance must be paid within 30 days from the start of the program. If a special payment arrangement is required, a written request must be submitted to Leadership Lackawanna upon acceptance into the program.
Leadership Lackawanna has sole discretion to accept or decline such request. Individuals who discontinue or are dismissed from the program will not receive a refund.
Your application is not complete unless it is accompanied by the processing fee, your signature and the signature(s) of your employer and/or sponsoring organization.
The candidate must either live in or work in Lackawanna County.
Class size is limited. Completion of the application does not ensure a candidate’s acceptance into the program.

Leadership Lackawanna Application (for download in PDF format)

Leadership Lackawanna Application

First Name: M.I

Last Name

HOME ADDRESS:

HOME PHONE:

AGE (Voluntary): 20-24

25-34

35-54

55 and over

Personal Email:

Number of years you have lived in Lackawanna County:

Number of years you have worked in Lackawanna County:

Have you previously applied for participation in Leadership Lackawanna?

Yes
No
If yes, when

How did you learn about the Leadership Lackwanna Program?

EDUCATION

List your educational background, including high school, college(s), advanced degree(s), specialized training programs or professional institutes.

Name and Location of School	Dates	Degree(s)	Majors

EMPLOYMENT

Employer/Organization:

Title/ Position:

Address:

Phone:

Fax

Email:

Briefly describe your present responsibilities:

List previous employment, including active military duty, in reverse chronological order:

Employer	Title/Responsibility	Period of Service

List your business/professional affiliations/organizations:

Name of Group	Position(s) Held	Period of Service

COMMUNITY INVOLVEMENT

List your community, religious, governmental, social, and/or athletic activities.

List any of your professional or community-service awards/honors:

Describe the type(s) of community activities in which you would like to become involved:

COMMUNITY INTEREST
One of the goals of Leadership Lackawanna is to build a corps of community leaders who can utilize its talents and problem-solving abilities through shared perspectives and networking.

Indicate what you hope to accomplish through your participation in Leadership Lackawanna:

Indicate a personal goal that you have yet to accomplish:

TUITION / SCHOLARSHIPS

Tuition for the Leadership Lackawanna Program is $1,200.

A non-refundable $25 processing fee (payable to Leadership Lackawanna) must accompany the application. A deposit payment of $100 is required upon acceptance into the program. The remaining tuition balance must be paid within 30 days from the start of the program UNLESS a written request regarding special payment is submitted to Leadership Lackawanna upon acceptance into the program. Leadership Lackawanna has sole discretion to accept or decline such request. Individuals who discontinue or are dismissed from the program will not receive a refund.

Full and partial scholarships are available on a limited basis.

If you would like to request tuition assistance, please indicate the amount and explain the reason.

Amount Requested:

PARTICIPANT’S COMMITMENT

I understand the purpose of Leadership Lackawanna and if selected, I commit to attend all
monthly sessions. As a participant, I fully understand that should I miss more than two sessions,
for whatever reason, I may be dismissed from the program with no portion of my tuition refunded.
I understand that I will be required to work on a group project in addition to the sessions. I further
understand that this is a competitive selection process and due to space limitations, not all
applicants can be selected. My signature indicates I understand the above commitments and
agree to uphold them to the best of my ability.

Applicant’s Signature Date

SPONSOR’S AGREEMENT
(To be completed unless nominee is self-proposed)

A nominee for Leadership Lackawanna must have the support and commitment of his/her employer, as well as his/her sponsoring organization (if different than employer). The signatures of the employer and/or sponsoring organization (where appropriate) are required as an indication that the employer and/or sponsoring organization is/are in complete support of the nominee’s participation in Leadership Lackawanna.

Please indicate the support of the employer and/or sponsoring organization by checking the appropriate box(es). Financial support indicates your willingness to pay the applicant’s tuition associated with participating in the Leadership Lackawanna Program. Release time support indicates your willingness.

Employer(if applicable):

Financial Support Release Time Support

Address:

Phone:

Title/ Position:

Approving Officer Name and Title:

Approving Officer Signature:

Date:

Sponsoring Organization(If applicable)

Financial Support Release Time Support

Organization:

Address:

Phone:

Approving Officer Name and Title:

Approving Officer Signature:

Date:

Any questions should be directed to Nicole Barber at 570-342-7711 ext. 125 or by email to nbarber@scrantonchamber.com.

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