Leadership CORE Application Form

To be considered for participation in the Regional Chamber's Leadership CORE program, please complete the following application form. This must be received by Sept 6 at 5:00pm. Once submitted, your application will be reviewed by our Selection Committee. Our class will be finalized and all candidates will be notified of their status by Sept 15.

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* 1. First Name:

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* 2. Last Name:

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* 3. Employer (company name):

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* 4. Your Direct Supervisor:

Name:

Email address:

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* 5. Your phone number:

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* 6. Your work email address:

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* 7. Your Title:

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* 8. How long have you been in this role?

Less than 1 year

1-3 years

3-5 years

6-10 years

More than 10 years

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* 9. How long have you been employed by this company?

Less than 1 year

1-3 years

3-5 years

6-10 years

More than 10 years

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* 10. Please summarize your current job responsibilities.

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* 11. How do you feel you are performing in the following areas:

	Excellent		Average		Needs Significant Improvement	Unsure
Communication	Communication Excellent	Communication	Communication Average	Communication	Communication Needs Significant Improvement	Communication Unsure
Supervising	Supervising Excellent	Supervising	Supervising Average	Supervising	Supervising Needs Significant Improvement	Supervising Unsure
Coaching	Coaching Excellent	Coaching	Coaching Average	Coaching	Coaching Needs Significant Improvement	Coaching Unsure
Accountability	Accountability Excellent	Accountability	Accountability Average	Accountability	Accountability Needs Significant Improvement	Accountability Unsure
Conflict Resolution	Conflict Resolution Excellent	Conflict Resolution	Conflict Resolution Average	Conflict Resolution	Conflict Resolution Needs Significant Improvement	Conflict Resolution Unsure
Team Building	Team Building Excellent	Team Building	Team Building Average	Team Building	Team Building Needs Significant Improvement	Team Building Unsure
Workplace Leadership	Workplace Leadership Excellent	Workplace Leadership	Workplace Leadership Average	Workplace Leadership	Workplace Leadership Needs Significant Improvement	Workplace Leadership Unsure
Strategy/Goal Setting	Strategy/Goal Setting Excellent	Strategy/Goal Setting	Strategy/Goal Setting Average	Strategy/Goal Setting	Strategy/Goal Setting Needs Significant Improvement	Strategy/Goal Setting Unsure

Comments:

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* 12. Within your current company, what is your ideal role or area of responsibility? What is your ultimate career goal and how do you plan to get there? Please explain. If you're not sure of your goals/plans, please share that here with some detail - it's OK to not know!

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* 13. Consider specific skills that are important in reaching your career goals. Would it be helpful to have access to resources/training in any of those areas? Please mark all that apply below:

General Public Speaking

Professional Presentations

Professional Writing

Time Management

Meeting Facilitation

Dealing with Stress in the Workplace

Professional Confidence

Other:

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* 14. Please share the name of an individual who you feel is an effective leader and explain why. Do you feel that you have any particular management or leadership skills in common with that person?

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* 15. Have you ever taken the StrengthsFinder Assessment?

Yes

Unsure

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