Political Leadership Form

Name

Preferred Nickname

Address

City

State

Phone

Zip

Date of Birth

Current Employer

Employer Address

City

State

Zip

Phone

Title

Preferred Communication for Contact Re: This Program

Email Mobile Work Phone

Date of Application Submission:

In this inaugural program. applications are open to members of LAKE 100 or a designated surrogate. If you are NOT a member, this does not mean you cannot participate.

Are you a member, or your employer, a member of LAKE 100

Yes No

If your employer is a member and you are not listed as the designee, who is the designated member for your company?

If you are not a member of LAKE 100, is there a LAKE 100 member recommending you for this program? If yes please provide the name of the LAKE 100 member recommending you:

Applicant Information

How long have you lived at your current residence?

In which month and year did you first register to vote at your current residence to the best of your recollection.

The Lake County business community faces a number of important public issues. In your opinion, what is the most important public policy issue or concern (please mention ONLY one) facing the business community in Lake County? Please share an idea, solution or approach on how you might address the issue you have identified, if appointed or elected to a leadership opportunity. (please limit your answer to 300 words or less)

At this moment, are you more interested in learning how to: (please choose only one)

Run for office Land an appointment to a government board or commission Other

If other please be specific:

Do you have a current timeframe for when you might run for office or seek an appointment? If yes when?

Have you ever held an elected or appointed office, including service on a government board, task force or commission at any level? If yes please list the office(s) or board(s), years served and title(s):

Have you ever ran for elected office?

Yes No

If yes, What/Where was this office? When was the election? What was the outcome?

Have you ever been a paid employee or served as a paid consultant/service provider/vendor to a political campaign?

Yes No

If yes, what was your role? and What was the names of the campaign(s) and in what year(s) ?

What are three things that you would like to learn, in order, If chosen to participate in the program? (please answer using 150 words or less)

Have you ever been convicted, pled no contest, been placed on probation, fined, entered a pre-trial intervention program or had adjudication withheld by any judicial or quasi-judicial body for any felony or misdemeanor other than minor traffic violations?

Yes No

What is your registered political affiliation (including no party affiliation)?

Please carefully review this program’s highlights and information found on the Lake100 website under Events. With this information, share your reasons for why you wish to be included in this program. (please answer using 300 words or less.)

Please provide the names and requested contact information for at least two personal or professional references.

Reference One:

Reference Two:

Applications are due by January 30, 2025 and notifications of eligibility will be made February 3, 2025. Dates of all courses may be found at Lake100.com and payment upon acceptance into this program will be due on or prior to February 13, 2025. You will be contacted by a member of Lake100 Administrative Leadership or a Board Member to collect payment via phone or through an email link.

Headshot

Resume or Bio

Prior to your final file upload submission of this application, your bio, and your headshot, please check off the following disclosures:

I have read and understood this is a non-partisan program and campaigning or negative discourse/attack/protesting is NOT allowed in these sessions. Should I choose to run for office at any time in the future, I understand that admittance into the program does not guarantee a future candidate endorsement or support from LAKE100 or anyone involved with the program directly or indirectly. I understand that full attendance is strongly encouraged during all three sessions: Thursday, February 13, 2025; March 13, 2025; April 10, 2025, and May 8, 2025 from 8:30 - 4:00 each day in order to graduate from the program. Breaks and lunches will be provided. I understand that should I be selected, a $250 course fee will be required by the first class.

Yes, I agree No, I disagree

Name

Signature

In this inaugural program. applications are open to members of LAKE 100 or a designated surrogate. If you are NOT a member, this does not mean you cannot participate.

Applicant Information

Please provide the names and requested contact information for at least two personal or professional references.

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