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Leadership Robins Region Application
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Last Name
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First Name
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Middle Initial
Preferred Name for Name Badge
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Name Exactly as it should appear on Graduation Certificate.
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Position Title
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Present Employer
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Name of Supervisor
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Business Address
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City, State Zip Code
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Office Phone
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Cell Phone
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Preferred
Email Address
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Alternate Email Address
(if desired)
Home Address
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City, State Zip Code
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Birthplace
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Number of Years lived in Georgia
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What do you hope to gain from your participation in the Leadership Robins Region Program?
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What are the three most pressing issues facing the Robins Region today?
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Briefly describe your responsibilities in your employment.
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What do you consider your most significant contribution of achievement related to your position so far?
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Please list civic organization involvement, public offices held, and or political activities.
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High School
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Undergraduate School
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Advanced Degree(s)
Other
List activities, offices and recognition for special contributions.
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