____ Yes, I am interested in participating in LEADERSHIP METCALFE.  I understand that this program requires my commitment to attend all sessions and 2 Civic/government meetings. I have discussed this program with my employer and my employer will accommodate my time commitment.

Please print.

NAME:_____________________________________________        DATE: ________________________

ADDRESS_____________________________________________________________________________

CITY, ST, ZIP __________________________________________    PHONE: ______________________

EMAIL ______________________________________________________________________________

EMPLOYER __________________________________________________________________________

SCHOOLS ATTENDED/GRADUATED  ____________________________________________________

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I am interested in participating in LEADERSHIP METCALFE COUNTY because:

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Applicant Signature                                                               Employer Signature