Name _______________________________________________________ Date __________________

Home Address _______________________________________________________________________

City ____________________________________________ State _________ Zip __________________

Birth date: _____/_____/_____

Home phone ______________________________ Work phone _________________________________

Fax number ________________________________ e-mail _____________________________________

Present Employer ______________________________________________________________________

Business Address ______________________________________________________________________

City ___________________________________________ State _________ Zip _____________________

Type of Business _______________________________________________________________________

Your Title _____________________________________________________________________________

•  I prefer to receive correspondence at:  Home Business
  

List prior employment, listing the most recent first:
Employer                               City / State                  Dates of Employment               Position Held
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

List educational background, including high school, college, university, etc., beginning with your
highest degree or latest accomplishment:
School                                      Dates Attended                            Degree or Accomplishment
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Please attach two (2) letters of recommendation addressing why you should be selected to participate in the Leadership Idaho Agriculture program. Complete the following information about your references:

Name ________________________________________ Title/Position ______________________________

Address ________________________________________________________________________________

City __________________________ State ________ Zip ______________ Phone ____________________

Name ________________________________________ Title/Position _______________________________

Address _________________________________________________________________________________

City __________________________ State ________ Zip ______________ Phone _____________________

List your past and current leadership involvement - include high school, college, community,
government and employment.

Organization                    Membership / Service Dates                          Your Involvement
_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Please attach a typed essay, one-half to one page in length, explaining why you want to be selected as
an LIA participant and how you plan to use the knowledge and experience you will gain as a participant.

Please indicate below how you want your tuition handled:

_____ I will pay the full amount

_____ My sponsor* will pay the full amount

_____ My sponsor* will pay a partial amount of $______________

*Sponsor signature if agreeing to pay full or partial amount of tuition: ________________________________

Sponsor's Address __________________________________________________________________________

City/State/Zip ______________________________________________________________________________

The remainder of my tuition will be paid by _______________________________________________________

LIA participants are required to attend ALL FOUR (4) PROGRAM SESSIONS in their entirety. Each session is 4-5 days in length. Graduation is contingent upon completion of ALL FOUR (4) sessions.

If I am selected as a participant in LEADERSHIP IDAHO AGRICULTURE, I will attend as a representative of ___________________________________________________________________

I agree to attend every session of LEADERSHIP IDAHO AGRICULTURE.

                      Applicant's Signature ________________________________ Date ___________________

LEADERSHIP IDAHO AGRICULTURE participants must have the support and commitment of their families and employers as well as the sponsoring business or organization. LIA requires a significant time commitment.

                      Employer's Signature ________________________________ Date __________________

*  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *
Application, including all required signatures, two (2) letters of recommendation, and essay, MUST be received by:
August 1 for the fall session (November, December, January, February).

Return to: Leadership Idaho Agriculture Foundation
55 SW 5th Avenue, Suite 100                                                 phone: 208-888-0988
Meridian ID 83642                                                                  fax: 208-888-4586