Leadership Rogers County Application
Please fill out your information below. Application Deadline: August 29th.

The Entire program cost is $400 per person.

To aid in the selection process, please check the category below which best describes the area in which you presently work/serve. Please check only one category. *
Personal *
Name: Last, First, Middle
Your answer
Home Address *
Street, City, State, Zip
Your answer
Contact Info *
Phone Number
Your answer
Email *
Your answer
Length of Residence or Employment in Rogers County
Your answer
Length of Residence in Oklahoma
Your answer
Do you plan on being a resident of Rogers County for the next 5 years?
Your answer
Have you previously applied for participation in Leadership Rogers County?
Your answer
How did you hear about Leadership Rogers County?
Your answer
Present Employer
Your answer
Employer's Phone #, Fax #, Email
Your answer
Employer's Mailing Address
Your answer
Employment Date
Your answer
Date Began Present Position
Your answer
Position
Your answer
Briefly describe your responsibilities
Your answer
Previous Employment (beginning with most recent) List 2 previous or last 5 years. Employer Title From To Reason for leaving
Your answer
List your educational background, beginning with high school. Include college, business or trade schools and/or specialized training. Name & School Location Dates-From/To Degree
Your answer
Please list, in order of importance, your key community, civic, professional, business, religious, social, athletic, and other organizational involvement. Organization Dates Position
Your answer
What do you consider your most significant contribution or achievement related to your community?
Your answer
In your opinion, what is the most significant challenge facing Rogers county or your community? What plan of action would you consider to address this challenge?
Your answer
Please explain why you wish to participate in Leadership Rogers County.
Your answer
Please provide two references who have worked with you on community activities or employment. Name Title Organization Phone
Your answer
APPLICANT’S COMMITMENT The program consists of nine monthly sessions. Classes are generally one week day a month lasting from 8:30 a.m. to 2 p.m. Classes are generally held in locations that best relates to the topic. This frequently requires traveling from site to site during the session. This program requires a definite commitment of time on the part of the participant. Attendance is mandatory for successful completion of the program and graduation. I understand APPLICANT’S AGREEMENT The completion of this application does not ensure my acceptance in the class and that I will be notified after the selection process has been completed. That Leadership Rogers County is a learning experience and my attendance is mandatory. My absence from more than 1 1⁄2 sessions will make me ineligible to graduate. Missing one (1) to four (4) hours will count as 1⁄2 day missed. Missing five (5) to eight (8) hours will count as a full day missed. That the first session is mandatory with no exceptions. The purpose of the Leadership Rogers County program, and if selected, will devote the time to complete the program. If appropriate, I have the approval and consent of my employer to participate in Leadership Rogers County. The commitments above and agree to be bound by them in signing this application. *
Your answer
EMPLOYER’S AGREEMENT (if applicable) This applicant has the approval of this organization to attend Leadership Rogers County. I agree, support and understand the attendance requirements set forth above. *
Your answer
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