LEADERSHIP ANSON
DEVELOPING A COMMITMENT TO COMMUNITY THROUGH LEADERSHIP

Sponsored By:
Anson County Chamber of Commerce
Hornwood Inc.
South Piedmont Community College

Leadership Anson Application

Please type or print legibly//Attachments of additional information are acceptable

*PERSONAL DATA

Name____________________________________________________________________________________
                               Last                               First                               Middle                               Preferred

Date of Birth ____________________ Sex:_____________________ Race:________________

Home Address___________________________________________________________________________________
                               Street                               City                               State                               Zip Code

Home Phone Number: ___________________________ E-mail Address: ____________________________

*EMPLOYMENT

Employer: _________________________________________________ Full Time: _______ Part Time: _______

Business Mailing address:_____________________________________________________________________
                                                    Post Office Box # and/or Street             City/State             Zip Code

Work Phone #: _______________ Work Fax #: _______________ E-mail:__________________________

Position/Job title:_____________________________________________________________________

Responsibilities __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


     *SCHOLARSHIP INFORMATION
Funding for scholarships is available on a limited basis, and is offered if an applicant is not being sponsored by their employer, church, club or organization. Scholarship applicants will be interviewed by a Leadership Anson Oversight Committee sub-committee.
Please check the appropriate box below if you would like to be considered for a scholarship.
          ___ Full Scholarship @ $350.00           ___ One-Half Scholarship @ $175.00








     *EDUCATION
     Please include high school, colleges, advanced degrees and/or specialized training.


Name and Location of School

From-To

Degree

Major


















Please list special awards for academic performance.

_________________________________________      ________________________________________

_________________________________________      ________________________________________

Please list extracurricular activities (offices held, honors received, etc.)

_________________________________________      ________________________________________

_________________________________________     _________________________________________

     *COMMUNITY INVOLVEMENT
     Please list community involvement activities.

_________________________________________      ________________________________________

_________________________________________      ________________________________________

_________________________________________      ________________________________________

_________________________________________      ________________________________________

     Please mark the categories which describe your areas of leadership activity and interest.

      ___ Social Services   ___ Government   ___ Business/Industry   ___ Religion   ___ Art

     ___ Medical/Health   ___ History   ___ Media   ___ Law   ___ Education   ___ Other: __________

* FOR MORE INFORMATION
Leadership Anson is a complete learning program to develop community leaders from all walks of life. Sessions begin in January with a mandatory overnight retreat. Following the retreat, sessions will be held every other Tuesday beginning on the last Tuesday in January. The class sessions end in June with a graduation ceremony.
Send applicatons to: Leadership Anson, c/o Anson County Chamber of Commerce
                                     P.O.Box 305, Wadesboro NC 28170-0305
For More Information, call 704-694-4181
or E-mail ansonchamber@windstream.net or go to www.ansoncounty.org

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