Online Application
   
Submit No Later Than July 22, 2011
For Printable Version, click here
 
Leadership Newark is a 501 (C) (3) charitable organization. Fellows are selected on the basis of a demonstrable track record in the community, leadership ability and professional achievement. Leadership Newark seeks visionaries and those committed to the concept of servant-leadership, which is first serving others to then lead and serve for the common good.. Please answer questions thoughtfully. Required fields in blue.
 
Last Name First Name MI Nickname, if applicable
Address 1 Address 2 City Ward State Zip Code
Home Phone Home Fax Cell Phone (office use only)
Home Email Business Email

Employment Record
Current Employer Date of Employment Position/Title
Business Address 1 Business Address 2 City State Zip Code
Business Phone Business Fax Cell Phone (office use only)
       
Which of these categories best describe your present field of employment?
If 'Other,' please describe:
   
Please describe your present job responsibilities and the nature of your work.
   
Employment History (List most recent first)
Employer
Position/Title
Dates of Employment
to
to
to

Civic Involvement
List (in order of importance) your business, civic, religious or political memberships/professional affiliations.  
Organization Nature of Organization Position Active Dates
to
to
to
 
What do you consider your greatest responsibility and achievement related to your civic/volunteer work? Explain why.  
 

Personal Goals and Participation in Leadership Newark, Inc.
Please describe the unique qualifications you believe you will bring, which will add to the dynamics and diversity of Leadership Newark.  In your description, include why you are applying for the Fellowship and how you hope to benefit from your involvement in the program.

Vision for the Newark Community
A. Identify a challenge facing the Newark community.  How do you see yourself playing a role in resolving the challenge you have identified?
 
B. Identify types of community boards, committees or groups in which you would like to become active in the future.   Identify or explain what you would like to accomplish in those groups.

Education
Please begin with high school and list colleges, graduate education and/or specialized programs. (At least one entry required)
Name City State Years Major Degree  
 
 
 
 

Recognitions
List professional, academic, or civic honors and awards.

References
In addition to 2 Letters of Recommendations, choose people who know your leadership potential, your commitment to Newark and your accomplishments and list their name and daytime phone number below:
(1)
Name
  
(2)
Name
 
Phone
    
Phone
             
Emergency Contact    
Name Daytime Phone Evening Phone

Personal Background
Completing this section is voluntary.  The information will be helpful in ensuring that the class represents the diversity of Newark.  Leadership Newark strives to ensure each class reflects ethnic, geographic and professional diversity.
Age
Special Needs
Diet
Physical Challenge(s)
Other
How do you choose to describe your race and/or your ethnic background?
Male        Female

Applicant's Commitment
One is first a servant then a leader - Leadership Newark's program takes place one full business day each month from September 2010 through October 2011.  In year two, meetings are scheduled once monthly at the convenience of the group from November 2011 through June 2012.  Leadership Newark Fellows are expected to attend all seminars, training sessions, and activities. Keep in mind a retreat is scheduled in late September or early October all day for 2 days usually a Thursday through Friday. Participation in the entire opening retreat is mandatory. Candidates should have the support and commitment of their employers to ensure an understanding of the time commitment required for Leadership Newark participation.

Upon acceptance to the program, Fellows are required to pay a modest tuition to cover materials. This will be due at the time of acceptance. Notification of acceptance will be in late August.

Tuition for the Class of 2013 is $2,000 for the 2-year fellowship program. The non-refundable application fee of $25.00 will be applied towards the tuition for those accepted. All interested persons are encouraged to apply. We urge prospects not to let the tuition be a deterrent. Leadership Newark is generously supported by grants from foundations, corporations and donors, which allows us to keep the tuition reasonable.

Terms and Conditions
A. I understand I must submit two (2) letters of recommendation with this application or you may have them sent under separate cover directly to Leadership Newark, Inc., 50 Park Place, Suite 1410, Newark, New Jersey 07102-4301 or via email to leadnewark@verizon.net.
B. I understand I must submit a non-refundable application fee of $25.00 by check, credit card or PayPal directly to the office or via the LN website by hitting the "Donate Now" icon. Please indicate a notation stating this is your "application fee".
C. I understand the purpose of Leadership Newark. I will commit myself and my time to complete the program. After the conclusion of the education and training program, as a Leadership Newark graduate, I will continue to support the activities of Leadership Newark.
D. I understand the applicable tuition payment is due in full at time of acceptance, unless other arrangements have been made in conjunction with the LN office.
E. I understand all pictures taken at program events are the sole property of Leadership Newark, Inc. My signature below authorizes their use in promotional materials and articles about the organization.
F. I have the cooperation and support of my employer.
 
  Employer/Supervisor Name
   
  This electronic submission implies my consent to the terms and condition listed in lieu of my signature.
 
Submit By: July 22, 2011
 
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