2005		
APPLICATION
	MU STATE LEADERSHIP/GROWTH SEMINAR
	TAMPA MARRIOTT WESTSHORE

          Attach a passport
            size photo here

	 JUNE 16-19, 2005
For Office Use Only:                                                           
Postmark Date            		                  Postmark Deadline: March 1, 2005                                

Registration fee of $125.00 to be paid upon acceptance.                                                            
	Send nine copies to the committee.
PLEASE TYPE or COMPUTER DUPLICATE THIS FORM

______________________________________________________________________________
      First Name                    Middle                            Last Name     

                                                                                                                            __________________
                    Street                                       City                                                   Zip                                    
		
Name for Badge: ____________________ Phone ____________________/________________________Email__________________________________________
   						Home                  	           Business
 
Application Date_________________Chapter__________________________________ City_____________________________________________

For Roommate Preferences: Do you smoke?  Yes             No______          

Have you applied for Leadership/Growth before? Yes           No           If so, what year?________________                    

Birth Date: ____________________	                 __________________                    	 ______________________
                  Month   Day   Year            		Number Years in DKG		   Number Years in Education

I.DELTA KAPPA GAMMA INVOLVEMENT:

    A. Past Offices Held, Committees, Other Services Rendered:

    B. District, state, or international meetings or conventions attended (include year):
 
.   

       Present Position:                     ______________________                                       Upcoming Position_________________________________
									(If applicable)

II.  EDUCATION:
    College or University                                   Geographic Location                              Degree and Date

III. PROFESSIONAL EXPERIENCE:  (Retirees:  Please specifically list last position)
    A.  

     ________________________________            ______________________        ____________________ __        _________________          ______ 
     Current School or Assignment:                           Position(Be specific)  	  City                 		     County                 	 Years                   
	
    Employer other than county school system:

B.	Major Responsibilities:

  Return completed application to: Morita Hadlock, Chairman, Mu State Leadership Development Committee, 
				    1108 W. Lake Martha Drive, Winter Haven, FL 33881, (863)294-5436
					hadlockm@earthlink.net
				        Nine copies  One  picture							OVER

IV. PREVIOUS EMPLOYER

V. PROFESSIONAL INVOLVEMENTS AND ACHIEVEMENTS OTHER THAN SOCIETY: (most recent, specific)

   

VI. LEADERSHIP IS THE ABILITY TO INFLUENCE OTHERS.

    A. How do you anticipate helping your chapter and Mu State through the skills you develop at the seminar?

   

    B. How do you anticipate helping your community?

    C. How do you anticipate helping your profession?

    D. Qualities that best describe you are: (three words only)

         1                                                  ___ 2                                              ____ 3____________________                 
 
    E. What do you consider the major contribution you have made to the Society the past year?

 
    F. What do you consider the major contribution you have made to education the past year?

 

VII.WHAT COMMITMENTS DO YOU HAVE OUTSIDE OF YOUR JOB AND DELTA KAPPA GAMMA? (family, church, community, 
       other  professional organizations ) 

   

VIII.WRITE FOUR STATEMENTS ABOUT YOURSELF THAT CONVEY THE MOST IMPORTANT ASPECTS OF WHO YOU ARE,   
        YOUR INTERESTS, YOUR PHILOSOPHY OF LIFE: 

   

   

NOTE: If any change in your activities, professional or otherwise, occurs between now and March 1, 2005, please send the chairman an addendum noting this for your application.