APPLICATION
Ohio LEAD Program Class XII
 

   232 Agricultural Administration Building, 2120 Fyffe Rd., Columbus, OH 43210
   Phone: 614-292-6021  Fax:  614-292-4294  Email:  marcou.3@osu.edu

   May be completed on-line. 

 

 Full Name:     Sex

 

 MailingAddress:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
County
Work Phone
Home Phone
FAX
E-mail

 Marital Status   Spouse's Name
 Date of Birth   Age
 U.S. Citizen
 Ohio Resident

 Current Occupation
 Company of Farm Name
 Nature of Organization

  Indicate your past and current membership and offices held in organizations, including high school, college, agricultural, civic, church, governmental, fraternal, and professional.

   Organization How long a member?  (Give dates)  Offices held, if any (Give dates)

  List all schools attended including high schools and/or college(s).

Name of School Attendance Dates Date of
Graduation		  Degree Major/Minor Field

 Business and/or Other Work Experience: (Use separate sheet if necessary)

Position Company/Organization Location Dates Employed

Briefly explain why you would like to participate in the Ohio LEAD Program: (200 words or less)

   List three issues that you feel are facing the food, agriculture and environmental sectors:  (Your issues may only address one of these areas and that is okay.) 

            Issue 1
             

            Issue 2
           

            Issue 3
           

   Briefly describe what you hope to gain from participating in the Ohio LEAD Program: (200 words or less).

  

 

List 4 references (two business and two personal) whom we may contact to assess your potential for      leadership in the agricultural industry.   Unless you indicate otherwise, it is assumed  these people  will be the same persons you ask to provide letters of recommendation.

Business (2) Personal (2)
Name
Street Address
City
State/Province
Zip/Postal Code
Home Phone
Name
Street Address
City
State/Province
Zip/Postal Code
Home Phone
Name
Street Address
City
State/Province
Zip/Postal Code
Home Phone
Name
Street Address
City
State/Province
Zip/Postal Code
Home Phone

            I understand the Ohio LEAD Program has time commitments for my participation in the Ohio LEAD Program and give my permission for contact of the references supplied.  I hereby certify that all statements made in this application are  true and complete.   I agree and understand that any misstatements or omission of material facts herein may cause disqualification of my application.  I understand  that  selection  of applicants is the sole responsibility of the Selection  Committee of the Ohio LEAD Program.

I understand that I will be expected to attend all program activities unless permission has been granted by the Ohio LEAD office. 
 

Ohio LEAD Program    
John M. Buck, President of the Ohio LEAD Alumni Association  
7632 Wildcat Pike
  New Bloomington  Ohio  43341
(614) 623-6086

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