Leadership San Jose Application

Fields marked with an * are required.

Personal Information

First Name *

Last Name *

Date of Birth *

Pronouns

Address Line 1 *

Address Line 2

City *

State *

Postal Code *

Personal Email *

Work Email *

Preferred email used for LSJ Communications *

Share your Headshot *

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Employment Information

Employer *

Current Job Title *

Current Job Description *

Employer Address *

Street, City, State, Zip

Manager/Supervisor: *

Manager/Supervisor Email: *

Industry Sector: *

Activities

Activities Question One *

List any leadership programs you have participated in previously:

Activities Question Two *

List the major civic, business, and professional activities in which you have participated during the past three years. Indicate the nature of your participation, including any offices you have held.

General Information

Question One *

Describe what you hope to contribute to the LSJ Cohort and what you hope to gain from the experience.

Question Two *

Please identify and explain a particular issue, opportunity or challenge you feel is crucial to the future of San Jose.

References
List two (2) people (personal or professional) who have knowledge of your qualifications and can speak to your suitability for the LSJ Cohort Program.

Reference One *

Provide:

Name
Email
Phone Number
Title
Relationship

Reference Two *

Provide:

Name
Email
Phone Number
Title
Relationship

Tuition
The tuition for Leadership San Jose Cohort Program is $3,500. The full tuition amount is due no later than August 15th, 2023. Each participant, as an indication of personal commitment, is expected to personally contribute $100 to the program tuition. Other sources, such as an employer or sponsoring organization, may be utilized to provide the balance.

Tuition *

Do you understand the statement about tuition

Important Dates
• Application Deadline: August 18, 2023 • Opening Retreat: September 22, 2023, 8:30 am to 5:00 pm • Class meets every 3rd Thursday of the month (October - June, 8:30 AM - 4 PM) • Graduation Dinner: June 20, 2024, 5:30 - 8:30 PM

Important Dates *

Do you acknowledge the above dates?

Policies
Refund Policy Withdrawal from the program following confirmation of participation will result in forfeiture of tuition unless an alternate participant is confirmed prior to the first session. Attendance Policy The opening retreat for Leadership San Jose will take place on September 22, 2023 from 8:30 AM to 4 PM. The retreat will take place at a local venue to be announced prior to the retreat.

Policies *

Employer / Sponsor Commitment
Employer/Sponsor Commitment Leadership San Jose Cohort nominees must have the support and commitment of their sponsoring business or organization. The signature of the head of the sponsoring organization or the nominee's immediate manager is necessary as an indication of that support.

Manager/Sponsor Approval

I agree to get a physical signature from my manager or sponsor prior to the date on which the application closes.

Sponsor Information if any:

Name, Organization, Title, Email, Phone

Declaration Upon Completion of Application
In submitting this application, I hereby declare that: I have read the above statements and agree to the refund and attendance policies. Except for circumstances beyond my control, I will complete the program in its entirety.

Digital Signature *

Leadership San Jose Application

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