PLI app final PLI of Polk 2.0 2019 proposed application (fillabl | Page 2
The Policy and Public Leadership Institute of Polk County
Application
Deadline: Friday, April 19, 2019
To thoroughly complete this application, you will need to expand on the space provided below.
SUBMIT ONLY ONE DOCUMENT WITH THE FOLLOWING: Add an up-to-date biography, CV or
resume following this application and include a directory-style photo in jpg or gif format below.
Applications must be returned to [email protected] in either MSWord® or pdf by Friday,
April 5.
Incomplete applications will not be considered.
Please attach a directory-style photo with your application
submission
Date submitted: ____________
Proper full name: _________________________
Preferred/common first name: ____________________
Date of Birth: _____________
Current Employer, your title and work address:
______________________________________________________________________________
______________________________________________________________________________
Work phone: _________________
Mobile phone: _________________
Best e-mail address (required) for us to notify you: __________________________________________
Complete residential address: _________________________________________________________
Have you filed as a candidate for political office or do you plan to file?
Yes
No.
If yes, please state the office and date of filing: ______________________________________________