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Required Field are marked with a *
Click here to download the
application for later use.
DEADLINE FOR SUBMISSION IS JUNE 6th, 2008 |
| About You: |
| *Name: |
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| *Address: |
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| *City: |
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*State: |
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*Zip: |
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| *Home Phone: |
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Home Fax: |
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| Business Phone: |
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Business Fax: |
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Business
E-mail: |
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Home E-mail : |
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| Place of Birth: |
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| *Ethnicity: |
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| *Sex: |
Male Female |
| Civic/Volunteer
Work - list in order of importance to you. |
| 1) |
Name of Organization:
Your Involvement:
Years: |
| 2) |
Name of Organization:
Your Involvement:
Years: |
| 3) |
Name of Organization:
Your Involvement:
Years: |
| Briefly describe you two major contributions
or achievements in you civic/volunteer work: |
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| Describe any barriers which have
kept you from becoming active in your community: |
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Have you ever held a leadership
position in your neighborhood, church, civic, or other organization?
Yes
No |
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If yes, please explain.
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| Have you held an elected position,
or ran for office? Yes
No |
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If yes, please indicate the
position and outcome of the election.
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| Educational
Background |
| Check: |
GED -
High School Grad - Some College -
College
Grad -
Other |
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List leadership training with
dates.
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Do you have mentor?
Yes No |
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Have you ever had a mentor?
Yes No |
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Name and address of your
local/ethnic newspaper
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| * |
Select your age range: |
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Current and Previous Employment |
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Current employers name: |
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Address:
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City:
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State:
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Zip:
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Your title: |
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How long have you worked there? |
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Previous employers name: |
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Address:
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City:
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State:
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Zip:
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Title: |
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How long did you work there? |
| Other Information |
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What significant
contribution/achievement have you made in your current employment?
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Previous employment?
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Chosen participants are expected to
remain active in their local neighborhood, civic. and/or community
organizations/activities. Will you be able to begin and/or continue in
this community building effort?
Yes
No |
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Please elaborate how?
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| * |
If chosen I commit to attendance at
the six all day Saturday institutes.
Yes |
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GINJ 24 Grant Street, Newark, NJ 07104 |
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