EmailMe Form - Application for VVL Class XV

Your Name *

First Last

Nickname or Preferred Name

Length of Residence in the Verde Valley *

Do you have any criminal convictions? *

Yes

No

A conviction does not necessarily disqualify an applicant from VVL

If "Yes" above, please explain

Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Physical Address (if different from mailing)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Phone *

### - ### - ####

Alternate Phone

### - ### - ####

Email *

Confirm

Spouse or Partner's Name (if applicable)

Employer *

Supervisor's Name *

Employer / Supervisor's Contact Info *

Personal Reference

Name of Reference *

First Last

Reference's Phone *

### - ### - ####

Brief Explanation of Your Relationship *

Do you have the full support of your employer for the time required to participate fully and effectively in Verde Valley Leadership? *

Yes

No

In the fields provided below please briefly respond to the following questions:

Describe the duties and responsibilities of your current job: *

Describe your educational background: *

In order of importance to you please list your community, civic, professional, religious, and/or social organizational membership/activity involvement: *

Please describe any leadership roles you have held in the groups identified above as well: *

Identify two significant challenges we face in the Verde Valley. Why do you think these are significant community issues, and what do you see as possible solutions? *

What do you hope to gain from being a part of Verde Valley Leadership? *

How did you hear about the Verde Valley Leadership program? Did someone recommend you to VVL? If yes, please specify. *