Mailing Address: 4601 College Blvd. l Farmington, NM 87402 l Phone: 505.320.2236

MISSION STATEMENT

The mission of Leadership San Juan is to identify, enlighten and encourage emerging leaders in diverse backgrounds, occupations and cultures for the purpose of enhancing the quality of leadership in our communities.

Have you previously applied to and been interviewed for Leadership San Juan? *

Yes

No

If so, how many times? *

Please note: Only one member of a household will be selected for the upcoming class.

I. PERSONAL

Prefix *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Cell Phone Number *

Email Address *

Ethnicity *

Do you plan to make San Juan County your permanent home? *

Yes

No

How many years have you lived or worked in San Juan County? *

II. EMPLOYMENT

Present Employer *

Date of Initial Employment * +

Type of Business *

Your Title *

Are you subject to transfer with your business/organization? *

Yes

No

III. EDUCATION

State your educational background in 350 words or less. Please include degrees awarded (college), field of study, professional institutes, other training programs, etc. (You may upload your resume as an attachment) *

0/350 words

Resume Attachment

IV. CURRENT OCCUPATIONAL RESPONSIBILITIES

Briefly describe your current occupational responsibilities in 350 words or less: *

0/350 words

V. CIVIC INVOLVEMENT

In 350 words or less, list the major civic, business and professional activities in which you have participated during the last five (5) years. Include office held, awards and/or special recognition. Also include elected offices and/or appointed committee/commission participation. *

0/350 words

VI. AREA OF INTEREST

In 350 words or less, what is your area of particular interest in community leadership (e.g., education, human services, government, etc.), and what do you feel you can contribute to the community in this area? *

0/350 words

VII. PRESSING PROBLEMS

In 350 words or less, in your judgment, what are the two (2) most pressing problems facing San Juan County? Why? *

0/350 words

VIII. SAN JUAN COUNTY IN THE FUTURE

Describe San Juan County twenty (20) years from now in 350 words or less. *

0/350 words

IX. TUITION

Tuition for Leadership San Juan is $800. A limited amount of funds for tuition assistance will be available for participants in the program. If you need tuition assistance, fill out the tuition assistance application below.

After an interview in June, you will be notified of acceptance into the program in July. Tuition will be due by August 1, 2024.

X. REFERENCES

Please provide the names of three (3) business and or personal references.

Name *

+-

Address or Email *

+-

Phone *

+-

XI. PARTICIPANT’S AGREEMENT

Leadership San Juan requires each participant to attend one session a month from September through May. As a participant, I am willing to attend all functions sponsored by the program, and I understand that attendance is most important. Missing any combination of more than 16 hours of session time may result in my dismissal from the program and my tuition not being refunded. The program may also require some additional time for outside field experiences.

Will you be able to fulfill this time commitment? *

Yes

No

The class will be limited in the number of participants. If you are not selected for this year’s class, we encourage you to reapply next year. Completion of this application does not ensure a candidate’s acceptance into the class. Selection of participants will be based upon application, personal interview, and an effort to have a demographically diverse class. Interviews will be conducted during the month of June.

If selected to participate, I understand and agree to abide by the attendance requirements stated above. Attendance at the retreat is mandatory (September 6, 7, 8, 2024), and I will be able to attend.

Applicant Signature *

Date * +

My employer understands that participation in Leadership San Juan may require my absence from work for at least one day per month from September through May.

Employer Signature *

Date * +

Application deadline: May 15, 2024. Please submit the completed application and supporting documentation by this date.

LEADERSHIP SAN JUAN APPLICATION FOR TUITION ASSISTANCE

If tuition assistance of $400 or less would allow you to participate in the Leadership San Juan (LSJ) program and you would not otherwise be able to be involved, you may request assistance using this form.

A condition of accepting the tuition assistance is that you must complete the required LSJ curriculum within a two-year period. If that requirement is not met, you must reimburse the LSJ program the full amount that you received. Any deviation from this procedure would require LSJ Board approval.

This application will be reviewed by the LSJ Tuition Committee and recommended for approval or disapproval to the LSJ Board. You will be notified of the decision when you are contacted about your acceptance into the class.

Would you like to apply for tuition assistance? *

Yes

No

Prefix

First Name

+-

Last Name

+-

Home Mailing Address

City

Zip Code

State

Present Employer

Type of business

I request partial assistance for Leadership San Juan tuition in the amount of... (not to exceed $400)

The special circumstances behind my request are: (250 words or less)

0/250 words

You agree that by signing your name this becomes your electronic signature and you agree to the terms specified above.

Applicant Signature

Date +