First & Last Name *

Address Line 1 *

Address Line 2

City *

Postal Code *

Phone *

Number of years in the Roseville Area? *

Email *

Do you expect to be living in this area in the next 3 years? *

Yes

No

Current employer:

*Current employment is not necessary for enrollment

Employment date:

Business address:

Type of business:

Your title:

Briefly describe your responsibilities:

Previous employment (Begin with most recent)

Employer	Title/Responsibility	From - To
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What would you consider your highest responsibility, skill, or career achievement so far?

What are your career goals?

Education:

Begin with the most recent degree/diploma. 

School name/location	From - To	Degree	Major
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Major volunteer role at this time:

Organization:

Position:

Describe responsibilities:

Community involvement:

Please list in order of importance to you, other community, civic, professional, business, religious, social, athletic, and other organizations of which you have been a member. 

Organization	Dates of Membership	Official Positions Held
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What have you accomplished as a leader in any of the above organizations?

Please list any special awards/accomplishments:

What are your areas of interest for leadership involvement?

(e.g., education, human services, government, religion, etc.)

What do you hope to gain and how to you expect to utilize your Leadership Roseville experience?

What is a particular issue/opportunity/problem crucial to the Roseville community?

(Be specific) 

What are your community service goals?

How will your tuition be paid?

Tuition for each participant in Leadership Roseville is $1,400. Tuition is nonrefundable and must be paid prior to the first class.

Employer

Personally

Request general scholarship assistance

Other

Please provide the names of 2 businesses/personal references that we may contact:

Name	Address	Phone Number
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Are you available to attend each Leadership session, including the September 19-20 retreat?

Leadership Roseville requires participation on the following dates:

September 25-26* • October 16 • November 20 • December 18 • January15 • February 19 • March 19 • April 16 • May 21• June 18 (Evening graduation) 

*Mandatory retreat

Yes

No

Are you willing to share a room with another Leadership student for the reduced tuition?

There are a few spots available for a reduced tuition of $200 based on double occupancy rooms at the retreat.

Is your employer aware and in support of you joining Leadership Roseville?

In order for the Roseville Leadership Program to accomplish its stated goals, the full participation of each individual is necessary. Participation as a team member in a class project is a requirement of the program as are the guidelines stated below:

• More than two absences during the program year will result in being dropped from the program with no tuition refund.

• Late arrival, leaving early or any variation in excess of an hour will count as an absence

• Mandatory attendance at one Roseville City Council Meeting & one Commission Meeting of your choice.

• Full participation in the curriculum is a requirement for graduation. attendance requirement.

Partnership in the Roseville Leadership Program must have the support and commitment of your employer, if not self-employed.

Yes

No

If selected, will you devote the time required to participate? *

I understand the purpose of the Roseville Leadership Program and that the completion of this application does not ensure a candidate's acceptance in the current class. If selected to participate, I will devote the time required.

Yes

No

Do you have any dietary restrictions? If so, please list.

Size for a unisex t-shirt