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HOME
OUR CHAMBER
Join the Chamber
Find a Business
Cornerstone Members
Events
Business Resources
Our Team
Member Login
Media
Contact Us
PROGRAMS
Buy Local
Leadership
Professional Development
Advancing Modern Professionals in Douglas
Networking Events
Signature Events
ADVOCACY
Local
State
Federal
ECONOMIC DEVELOPMENT
Industry
Small Business
Workforce
Douglas Jobs
COMMUNITY
Community Guide of Douglas County
Map of Douglasville, Villa Rica, and Douglas County
Non Profits
Community Calendar
MarketSpace
JOIN
Leadership Douglas 2021-22 Application
BASIC INFORMATION
First Name
*
Last Name
*
Home Address
Address Line 1
*
Address Line 2
City
*
State
*
Select option...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
DC
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
DC
Zip/Postal Code
*
Home Email
*
Cell
*
Date of Birth
*
Gender
*
Male
Female
Ethnicity
*
Live in Douglas County?
*
Yes
No
How many years have you lived in Douglas County?
*
Work in Douglas County?
*
Yes
No
How many years have you worked in Douglas County?
*
PRESENT EMPLOYMENT
Employer
*
Business Address
Address Line 1
*
Address Line 2
City
*
State
*
Select option...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
DC
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
DC
Zip/Postal Code
*
Business Phone
*
Business Email
*
Title or Position
*
Briefly describe your job responsibilities
*
Prefer email at home or business?
*
Home
Business
EMPLOYMENT HISTORY
List in reverse chronological order for last 10 years.
Employer 1
*
Title
*
Period of Employment
*
Employer 2
Title
Period of Employment
Employer 3
Title
Period of Employment
BUSINESS/PROFESSIONAL AFFILIATIONS
If any - last three years only. (Use Community Involvement section for civic organizations, public office or political activities.)
Name of Group 1
*
Position Held or Assignments
*
Period of Affiliation
*
Name of Group 2
Position Held or Assignments
Period of Affiliation
Name of Group 3
Position Held or Assignments
Period of Affiliation
Most significant career achievement thus far?
*
COMMUNITY INVOLVEMENT
If any - last three years only. (Civic, public, religious and community involvement, etc.)
Name of Group 1
*
Position Held or Assignments
*
Period of Affiliation
Name of Group 2
Position Held or Assignments
Period of Affiliation
Name of Group 3
Position Held or Assignments
Period of Affiliation
Recognitions for special contributions?
SPECIAL AWARDS AND/OR HONORS & RECOGNITIONS
List below
EDUCATION
High School
*
College
*
Degree
*
Graduate School
Degree
Are you enrolled or planning to enroll in other education programs at the same time as LD?
*
Yes
No
Do you have any work related training or travel which may conflict with LD?
*
SHORT ANSWER ESSAYS
Please attach a separate document to respond - limit 1 page total.
Why do you feel community involvement is important?
What would you hope to gain from the Leadership Douglas program?
In your judgement, list in order the three most important issue facing Douglas County and note why they are important to you.
Upload Short Answer Responses
*
TUITION
A tuition fee is required to cover materials, monthly program expenses and retreat. If selected for participation, a minimum of 50% deposit is due at orientation in May, with the balance payable no later than June 25th. Tuition for Leadership Douglas is $800 for DC Chamber members in good standing. Tuition is $1,000 for non-DC Chamber members, which includes a one-year individual DC Chamber membership.
TIME COMMITMENT
Leadership Douglas has a mandatory time commitment for all 10 monthly, one-day sessions and an overnight retreat beginning August 2021. Attendance at all programs is mandatory. In addition, there is a class service project, book study, and occasional out-of-class assignments to go along with day programs. The time commitment is serious and participants not complying with the attendance requirements will be dropped from the program without tuition reimbursement. If selected, you aand your employer must be willing to make a commitment of your time. (2021 Dates: May 19, 4 - 6pm Orientation; July 27th, 5 - 7pm Introduction to Alumni; August 25-26 Retreat; October 7; November 5; December 9; December 9 Holiday Social. 2022 Dates: 1/5, 2/3, 3/3, 4/14, 5/5, May Graduation date TBD.)
ACKNOWLEDGEMENT
*
I have reviewed the 2021-22 Leadership Douglas Application and understand that the tuition cost is non-refundable should I not fulfill attendance requirements. I will attend all Leadership Douglas Program activities and look forward to being an active participant in the program. Applicant's supervisor and/or the CEO of the organization (or equivalent) is in support of the applicant’s participation in the Leadership Douglas Program.
Upload Additional Documents
*
The applicant must upload the document with the signature of approval by the CEO or supervisor. Download the signature document here: https://douglascountygeorgia.com/wp-content/uploads/2020/01/Leadership-Douglas-Application-Approval-document-1.pdf
Completed application MUST be received in Chamber office by 5 p.m., Friday, March 12th. No applications will be accepted after the deadline.
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