Leadership Burke - Burke County Chamber of Commerce

Name*

First Last

Headshot

A headshot or similar quality professional photo will be required. If you do not have one to upload, please email it as soon as possible to tstephenson@burkecounty.org

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.

Birth Date*

Gender

Male

Female

Other

Prefer not to say

Years you have lived in Burke County*

Any food allergies? If so, please specify.

Home Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone Number*

Work Phone Number*

Email*

Enter Email Confirm Email

Preferred Contact Method*

Email

Phone

Spouse/Partner Name

First Last

Names/Ages of Children

How did you hear/learn about Leadership Burke?*

Employer*

Date of employent*

Job Title*

Business Address*

Street Address Address Line 2 City State ZIP Code

Business Phone

Business Email

Please list three (3) prior employers.*

Include military active duty. Include: Employer Name | Job Title | Dates From-To

What do you consider your highest responsibility, skill or career achievement so far?*

Please list in order of importance to you, up to five community, civic, professional, business, religious, social, athletic, or other organizations of which you have been a member.*

Include Organization | Approximate Dates | Official Positions

Please list any recognitions, awards, and/or certifications you have received from your company or other organizations.*

Highest Level of Education*

Highest Level of Education - Extended Information*

Please List Name and City of School | Dates From-To | Degree | Major

Are there particular leadership skills that you hope to gain from this program?*

How much time each month do you commit to community, civic, professional or other organizations and activities?*

Have you been as active in community, and other activities as you would like to be? If not, what have been the major barriers to your becoming involved?*

If you have previously not had the time or interest to become actively involved, what conditions have changed that now enable you to seek involvement in the community?*

Which local volunteer agencies/organizations would you like to participate in during the next 12 months?*

Have you ever participated in another Community Leadership Program? If yes, please specify which one(s).*

What leadership courses or seminars have you attended in the past 5 years?*

Please write a statement of why you wish to participate in Leadership Burke and what you hope to gain from the experience.*

Where do you see yourself in five years?*

Are you a registered voter? If not, please explain why.*

Please list three (3) people who are knowledgeable about your leadership performance and potential.*

Include Name, Address, Phone Number

Preferred Payment Method*

There is a fee associated with Leadership Burke. Please select how you would like to pay for the course. Once we receive your application, you will then be sent the payment fee via your selected payment option below.

Debit/Credit (fees may apply)

Invoice my employer (must include employer email below)

Check

Cash

Employer Email

Enter Email Confirm Email

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2026 Leadership Burke Application