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2. Personal Data
4. Name (First, Last, Middle Suffix)
6. Home Address
8. Business Address
10. Where do you wish to receive correspondence?
12. Cell Phone
13. Business Phone
15. Personal Email
16. Business Email
18. Length of residence and/or work in Manhattan
20. Education
    College/Technical School/Other - List name and city as well as degree/professional training/certificates
22. Professional
    List employment in reverse chronological order beginning with your current position. Employer/Location/Title or Responsibility/Dates (From/To)
26. When thinking about the future of Manhattan, what excites and concerns you most? What would you hope to gain from the Leadership Manhattan program that would help you to sustain that excitement and address those concerns?
28. Civic Engagement / Community Involvement / Leadership Summary
    Please list the community, civic, political, athletic, cultural and/or other organizations of which you have been a member and that have been of significance to you. List Organization, From/To, Role/Involvement
30. Choosing one item from the list above, what is the most significant thing you have learned as a result of your community/volunteer involvement? How has this knowledge impacted your life?
34. Scholarship
    A Leadership Manhattan Scholarship may be available to help cover the cost of tuition for qualifying participants whose tuition is NOT paid for by their employer.
36. Would you like to apply for the scholarship?
    -- Select One --YesNo
38. Is your participation contingent on the receipt of the scholarship?
    -- Select One --YesNo
40. What amount of scholarship would allow you to participate?
42. If you are requesting a scholarship, please explain why.
46. Employer Commitment

    As the applicant's employer, I consent to his/her participation in the 2022 Leadership Manhattan Program and agree to the attendance requirements set forth on the program schedule. *Once your application has been submitted, instructions for signatures will be sent.

48. Name
50. Title
52. Email
53. Phone
55. Date
57. Participant Commitment

    In order to graduate from the 2022 Leadership Manhattan Program, participants must attend all sessions including an overnight trip to Topeka (see dates on page 1). I understand the goals of the program and the commitment required of class participants (including the $950.00 non-refundable tuition for Chamber members or $1,100 non-member). If selected, I will attend all sessions and I give permission for my name and/or picture to be used in future Leadership Manhattan publications. I certify that the information provided in this application is true and accurate.

59. Name
60. Date
62. Application Deadline
    APPLICATION DEADLINE Your completed application must be received on Monday, October 26, 2020 by 5 p.m. Please send/email applications to: Leadership Manhattan Manhattan Area Chamber of Commerce 501 Poyntz Avenue Manhattan, KS 66502-6005 leadership@manhattan.org For questions, please call: 785-776-8829 *Please note, you will receive an email response indicating your application has been received. If you do not receive a response within 24 hours after submission, please contact Sharla Meisenheimer at 785.776.8829.
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

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