Leadership Academy Application Form

Personal Information

Name

First

Middle

Last

Address

City

State/Province

Zip/Postal

Email

Home Phone:

Cell Phone:

Professional History

Current Employer:

Title/Position:

Work Address:

Job Description:

Professional Achievements and Highlights

Please describe any outstanding contributions made by you in your professional endeavors. List major business and professional activities in which you participated in the last five years.

Educational Background

Please provide the following information about your education: high school and beyond. List and describe extracurricular activities.

Civic Participation

Please describe any civic, political, social, or educational activities by listing the organization, how you made a difference and any awards or special recognition, if applicable.

Issue Focus

Please describe an issue important to our state and/or nation and your recommendations for a solution.

Leadership

Why do you want to be a part of the Mississippi Leadership Academy? How will you use the skills learned for the betterment of our state?

Future Ambition

What do you hope to achieve in the future in terms of public policy?

References

One letter of recommendation on your behalf must be submitted by application deadline for your application to be complete. Please provide the information of those who are writing your two letters of recommendation.

Name:

First

Last

Business:

Title:

Email Address:

Best Phone:

City:

State:

Zip:

Letter of Recommendation 1

Maximum file size: 516MB

Participation

The Mississippi Leadership Academy consists of five full-day session held one Saturday each month (with one exception), October through March, with December off for Christmas Break. Students are allowed one absence, but notice of absence must be given by the student to MSLA at least a week prior to MSLA sessions. Students will incur a $50 meeting fee for any unauthorized absence. Absences may be cause for dismissal from the program. Tuition is non-refundable, regardless if graduation status.

If selected into MSLA, can you devote the required time to this program?

Yes

No

MSLA Application Checklist

Completed application

Letter of recommendation #1

Once you have submitted your application, if you didn't attach the letter of recommendation above, please send the letter of recommendation to: Mississippi Leadership Academy, ATTN to Anika Page 520 George Street, Jackson, MS 39202 Email to Anika Page: [email protected]

Application Signature

Clear

I have read and understand the above statements and agree to the terms of the Mississippi Leadership Academy

Date