Leadership Southern Indiana - Developing and Training Leaders for over 25 years in Southern Indiana!

Contact Information
First Name:
Middle Name:
Last Name:

Name Tag:

Age:
Gender:	Male Female

Address:

City:
State:
Zip:

Phone:
Fax:
Email:

Work Information
Company:
Title:
Status:	Full-time Part-time
Years:

Address:

City:
State:
Zip:

Phone:
Fax:
Email:

General Information
Where do you wish to receive LSI correspondence?
	Home Workplace
Have you previously applied for Leadership Southern Indiana?
	No Yes (if yes, what year? )
Are you a graduate of Focus Southern Indiana?
	No Yes (if yes, what year? )
Can you be away from work the second Wednesday of each month?
	No Yes
Who will pay your tuition?
	I will My employer Employer and I will share fee
What can you contribute to Leadership Southern Indiana (i.e. skills, experience)?

What do you expect to gain from your participation in LSI?

How did you hear about applying for Leadership Southern Indiana?
	Newspaper Radio TV Personal Contact

Organization Information
Organization 1:
Member Date 1:
Position Held 1:

Organization 2:
Member Date 2:
Position Held 2:

Organization 3:
Member Date 3:
Position Held 3:

Organization 4:
Member Date 4:
Position Held 4:

Awards or distinctions earned (list the year):


Approximate number of hours per month that you can commit to community, civic, professional or other organizations:


Education Information
University:
Degree:
Major:
From:
To:

Address:

City:
State:
Zip:

References Information
Name 1:
Address 1:

City 1:
State 1:
Zip 1:
Phone 1:

Name 2:
Address 2:

City 2:
State 2:
Zip 2:
Phone 2:

Name 3:
Address 3:

City 3:
State 3:
Zip 3:
Phone 3: