Prefix

Name

Suffix

Address Line 1

Address Line 2

City

State

Zip/Postal Code

Phone Number

Email Address

Years Residing in Fairfax County

Years Working in Fairfax County

Are you a graduate of another Leadership Program? Are you a graduate of another Leadership Program? Yes No

Name of Employer

Job Title

Business Address Line 1

Business Address Line 2

Business City

Business State

Business Zip/Postal Code

Business Phone Number

Choose the sector(s) that best represents your professional occupation Choose the sector(s) that best represents your professional occupation Business Education Government Health Care Human Services Professional Services Military Public Safety

1. Employment Information: Briefly describe your current job responsibilities. What do you consider your most significant contribution or achievement related to your career so far?

2. Community Involvement and Volunteerism: In order of importance to you list three organizations in which you have volunteered or had a leadership role. Describe your role with each organization.

3. In your opinion, what are the two most important opportunities and the two biggest challenges facing this area of Fairfax County?

4. If you could accomplish one thing in our community what would it be and why?

5. What do you hope to gain from your participation in Leadership Mount Vernon Lee?

6. What do you hope to give back to the community after you complete this Leadership program?

Reference #1 Name

Reference #1 Title

Reference #1 Email

Reference #2 Name

Reference #2 Title

Reference #2 Email

If selected as a member of Leadership Mount Vernon Lee Class of 2022-2023, I agree to attend all of the function sponsored by the program. I understand the full-day attendance for each class is important to maximizing the experience and that I will not be allowed to graduate with my class if I miss more than 10 hours of class time. I also understand that any absence must be approved in advance. Failure to meet attendance guidelines will result in a withdrawal from the program and the forfeiture of my tuition. If selected as a member of Leadership Mount Vernon Lee Class of 2022-2023, I agree to attend all of the function sponsored by the program. I understand the full-day attendance for each class is important to maximizing the experience and that I will not be allowed to graduate with my class if I miss more than 10 hours of class time. I also understand that any absence must be approved in advance. Failure to meet attendance guidelines will result in a withdrawal from the program and the forfeiture of my tuition. I agree and understand the terms and conditions of this program.