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: ______________________________________________