Application Form

*Before you fill out this form, make sure the website address typed in has "www." at the beginning of the URL, otherwise it will ask you for a password.

Name:
Email:
Address:
City:
Daytime Telephone:
Alternate Telephone:
Profession/Industry:
Employer:
Office Location (City):
Civic Activities, Organizations

1. What issues should the city address or concern you the most?

2. What do you hope to gain from the Leadership Hermosa program?

3. What are you main reasons for joining this program?

4. What skills do you think you could bring to Leadership Hermosa Beach?

5. List the top issues facing Hermosa Beach and describe why they are significant.

Pledge of Time and Financial Commitment

In order to receive maximum benefit from Leadership Hermosa Beach’s objectives, I pledge my full participation and commit to attending no less than 7 of the 9 program classes in order to graduate. In addition, I will attend the mandatory Leadership Hermosa Beach Kick-off Retreat and agree to dedicate time as needed to complete the class project. I also agree to pay (or make provisions necessary to pay) the enrollment fee due upon my acceptance into the program.

Signature: Date: