Form Builder

Part 1 - Personal Information

First Name

Middle Name or Initial

Last Name

Street Address

City

State

Zip Code

County

Primary Phone Number

Primary E-Mail Address

Secondary E-Mail Address

How many years have you lived in Georgia?

Currently employed?

Employer (indicate “self” if self-employed)

Job Title

Part 2 – Demographics

Gender

Enter Gender

Race

Enter Race

Ethnicity

Enter Ethnicity

Religious Affiliation

Enter Religious Affiliation

Date of Birth

Part 3 - Education

Undergraduate Degree

Year

Major

Institution

Post-Graduate Degree

Year

Institution

Awards/ Honors/ Certifications you have received:

Part 4 - Leadership/Community Experience

Please limit responses to 150 words.

Please list any organization(s) with which you are or have been active. Please tell us your role in the organization:

Describe the impact that this involvement has had on you, the organization and beyond.

What skills have you acquired through participation in this (these) organization(s)?

Part 5 – Goals and Interest Areas

Please provide your reasons for participating in ISBLI and how you envision using your ISBLI skills to contribute to community life and civic engagement. Please limit responses to 150 words per response.

List three goals or objectives you hope to accomplish during your ISBLI experience:

List all skills you hope to improve through your ISBLI experience:

What impact do you intend to make on your community following your ISBLI experience?

Do you commit to being present in attendance of every session outlined in the program calendar and to complete the group project and community activities mandatory for the program?

*Note – a “No” answer may negatively impact your application

If you answered "No” please explain your reasons.

How did you hear about ISBLI?

Part 6 – References

Please provide the name and contact information of two references who can attest to your character, service, leadership, and community involvement.

First Reference:

Title (e.g., Mr., Ms., etc.)

First Name

Last Name

Name of Organization

Title/Position:

Telephone Number:

E-mail address:

Relationship to you:

Second Reference:

Title (e.g., Mr., Ms., etc.)

First Name

Last Name

Name of Organization

Title/Position:

Telephone Number:

E-mail address:

Relationship to you:

Part 7 – Payment Information

How will you pay the 2019- 2020 ISBLI tuition?

Payment Options

SINGLE PAYMENT (One payment for full amount of tuition)
THREE PAYMENTS (First payment 50% down plus two remaining monthly payments of 25% each)

All payments must be completed by Oct. 31, 2019

Payment Method

PayPal
Credit Card
Check

If you are applying for a scholarship, you must indicate a value in the next question.

Annual Household Income (approximate $s required if requesting financial assistance):

Please upload your resume or bio / biographical statement here (pdf, doc, etc)

Please make sure you have completed all fields and check for accuracy prior to pushing the SUBMIT button. Thank you.

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