Personal Data

Salutation (Mr. Ms. Dr. other)	____________________________________
First Name / Middle / Last / Suffix	____________________________________
Position/Job Title	____________________________________
Place of Employment	____________________________________
Employer Address	____________________________________
Employer City	____________________________________
Employer State	____________________________________
Employer Zip Code	____________________________________
Work Phone (include area code)	____________________________________
Work Fax (include area code)	____________________________________
Preferred E-mail	____________________________________
Male/Female	____________________________________
Birth Date	____________________________________
Race/Ethnic Identification	____________________________________
Disability	____________________________________

Sponsorship Data
Unless self-employed, applicants must have the support and commitment of their employer. They may be contacted by LPInc.

Sponsoring Organization	____________________________________
Address	____________________________________
City	____________________________________
State	____________________________________
Zip	____________________________________
Head of Sponsoring Organization:
Salutation: ____________________________   First Name / Middle / Last / Suffix: ____________________________   Job Title: ____________________________     Phone: ____________________________     Email: ____________________________
Tuition Assistance To request tuition assistance, please call or email the Leadership Pittsburgh Inc. office to request a form (412.392.4505 | info@lpinc.org). Participants seeking assistance will be asked to complete a statement of financial need. This form MUST be submitted with the application.

Please Include the Following:

Professional Experience
List past and present employers. Include title, a brief job description and dates of employment.

Educational Experience
List educational highlights. Include dates, degrees obtained, fields of study, training programs, and awards.

Professional Activities
List in order of importance, the employer-related or professionally based activities in which you participate or have participated. For each activity, state the nature of your participation including leadership positions or special recognition received, and the date(s) of your involvement.

Community Involvement
List in order of importance, the community and civic activities in which you participate or have participated. For each activity, state the nature of your participation including leadership positions or special recognition received, and the dates of your involvement.

Personal Insights

What is the one major issue facing the Pittsburgh region that you, personally, are concerned about? Why? Any recommendations for addressing this issue? (200-500 words or less).

Tell us about an experience or situation in which you assumed a leadership role. What prompted your role as a leader? (200-500 words or less).

Describe one life experience that had a significant effect on your personal development. (200-500 words or less).

References
Please list the names, addresses, phone numbers, and email addresses of two individuals who could attest to your leadership capabilities. Letters of recommendation are strongly encouraged, but not required. Letters of recommendation are due the same day as the LDI application. Do you know any graduate of Leadership Pittsburgh Inc.? Please list their names. (A directory of LPInc. graduates can be ordered via the website: www.lpinc.org.) Any of these individuals may be contacted.

How did you learn of Leadership Pittsburgh Inc. and Leadership Development Initiative?