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Leadership Mississippi Online Application

  1. Personal Data

  2. Full Name(*)
    Please let us know your name.
  3. Preferred Name for Name Tag
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  4. Date of Birth
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  5. Age
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  6. Male/Female
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  7. Race/Ethnic Background
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  8. Home Address
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  9. Business Address
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  10. Work Phone
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  11. Home Phone
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  12. Mobile Phone
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  13. Fax Number
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  14. Email(*)
    Please let us know your email address.
  15. If married, Spouse's Name and Occupation
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  16. How long have you lived in Mississippi?
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  17. Have you participated in another state or community leadership program?
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  18. If so, what is the name of the program?
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  19. Location of Program
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  20. Date of Participations
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  21. Have you ever been charged with a felony?
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  22. If yes, please explain:
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  23. Note: Conviction of a felony doesn’t automatically bar acceptance.

  24. Employment

  25. Present Employer
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  26. State Date
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  27. Job Title
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  28. Briefly describe your responsibilities in your position (Limit response to two lines).
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  29. What would you consider your most significant contribution or achievement related to your position so far? (Limit response to four lines)
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  30. Please check the category which best describes the area in which you presently work/serve:
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  31. If other, please describe:
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  32. Employment History (Beginning with the most recent - Limit response to four lines)
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  33. Education (High school, college(s), advanced degrees or specialized training - Limit response to four lines)
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  34. Activities, offices and recognition for special contributions in your education/training
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  35. COMMUNITY INVOLVEMENT (Please list in order of importance to you: community, civic, religious, political, government, social, athletic, or other activities with which you are involved or have been a member. Indicate role in organization. Limit response to four lines)
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  36. What do you consider your most important accomplishment in community or civic activities? Why?
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  37. What community awards or have you received? When?
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  38. In what kinds of additional volunteer/community/state activities would you like to become active in the future?
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  39. Contribution to Leadership

  40. What specific skills/knowledge do you hope to gain from your participation in Leadership Mississippi?
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  41. What specific skills/knowledge do you hope to contribute to the Leadership Mississippi program?
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  42. References

    Please list two people other than your sponsor who are knowledgeable about your leadership performance and potential. In addition to your references, two letters of recommendation should be submitted with the application. Send reference letters to: Leadership Mississippi, P.O. Box 23276, Jackson, MS 39225-3276. Please direct those that will submit a reference letter on your behalf to www.Leadershipmississippi.org to upload reference letter.

  43. Reference #1

  44. Name
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  45. Address
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  46. Phone Number
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  47. Reference #2

  48. Name
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  49. Address
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  50. Phone Number
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  51. Tuition

    If accepted into the Leadership Mississippi program each participant, financial sponsor, and/or employer will be billed for the tuition fee of $2,500 which covers all program costs, transportation during sessions, and meals.

  52. Will you pay the tuition fee?
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  53. Will your employer/sponsor pay the tuition fee?
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  54. If none of the above, who will be responsible for payment?
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  55. Employer Commitment

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  57. Commitment

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  59. Please attach a biography in Word or PDF format.(*)
    Application cannot be submitted until bio is uploaded.
  60. Application cannot be submitted until bio is uploaded.
  61. Please attach a recent photograph in JPG format no larger than 1MB
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  62. If you would like to send reference letters, click here.