PERSONAL DATA

Name______________________________________________________________________________________
              Last               First       Middle            Preferred First or Nickname
			  
Home Address_____________________________________________Home Phone_______________________
Mailing Address___________________________________________________________________________
Business Address__________________________________________________________________________
Business Phone____________________Fax________________E-mail_______________________________
Hobbies & Special Interests ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

EDUCATION
[Begin with high school, college(s), advanced degrees and/or specialized training]
A. Name & Location of School                       Date (from-to)       Degree/Major
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

B. Extracurricular Activities/Leadership Positions/Awards for Academic Performance
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

EMPLOYMENT
Present Employer______________________________________________________Since_______________
Type of Organization______________________________________________________________________
Title or Responsibility_______________________________________________Since_______________

A. Briefly describe your current job responsibilities:____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

B. List previous employment in reverse chronological order: (at least past 10 years)
      Employer                             Title/Responsibility      From      To
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

What do you consider your highest career achievement?_____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Business/Professional Affiliations:
(Not including civic organizations, public office or political activities)
          Name of Group         Positions Held/Assignment       Period of Affiliation
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

COMMUNITY INVOLVEMENT
(Please list, in order of importance to you, up to five community, civic, religious,
political, government, social, athletic or other activities of which you have been a
member. Do not include business/professional activities. Do not attach a separate list.)
           Organization          Dates of Affiliation             Assignment/Position
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

If you have additional significant community, civic, religious, political, government,
social, athletic, or other areas of active involvement, please list:______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

What do you consider your most important accomplishment in one of the above organizations?
Why?______________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

On the average, how much time each month do you commit to volunteer work?_________________
__________________________________________________________________________________________

In what kinds of additional volunteer activities would you like to become active in the
future?___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

If you have not had the time or interest to become actively involved, what conditions have
changed that now enable you to seek involvement in your community?________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

GENERAL INFORMATION
What specific skills/knowledge do you hope to gain from your participation in Leadership
Citrus?___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

What contribution do you feel you could make to the program?______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

REFERENCES
Name/Title________________________________________________________________________________
Business Address__________________________________________________________________________
Phone_____________________________________________________________________________________

Name/Title________________________________________________________________________________
Business Address__________________________________________________________________________
Phone_____________________________________________________________________________________

Name/Title________________________________________________________________________________
Business Address__________________________________________________________________________
Phone_____________________________________________________________________________________


EMPLOYER COMMITMENT: This applicant has the approval and full support of our organization.
We understand that this includes the time required to participate in the program.

Name/Title_____________________________________Firm/Organization__________________________
Signature___________________________________________________Date__________________________


COMMITMENT: I understand the purpose of the Leadership Citrus program and, if selected, 
will devote the time and resources necessary to complete the program. I understand that 
to graduate, a participant must attend the opening and closing sessions, plus at least 
80% of the remaining program sessions. If applicable, I have my employer's support as 
indicated above. I understand that even though emergencies do arise, any participant 
missing more than 20% of the sessions, for whatever reason, will be asked to withdraw 
from the program and no portion of the tuition shall be refunded. I agree to be bound 
by the above commitments by signing this application.

Applicant Signature_________________________________________Date__________________________