Springfield Leadership Workshop Application Please complete the following application to be considered for the October Springfield Leadership Workshop. Application Deadline Extended to: Friday, September 29, 2017 Workshop Dates: 12:00pm - 5:00 pm; Tue. October 3, 2017 @ SUB Board Room; Wed. October 4, 2017 @ City Hall; Thurs. October 5, 2017 @ SUB Board Room Fees: $95 if you apply before 09/08/2017 - $125 after 09/08/2017 First Name Last Name Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DC Zip/Postal Code * Email: Home Phone: Cell Phone: Work Phone: Business Name (if applicable) Occupation or areas of expertise: Why are you interested in attending the Springfield Leadership Workshop? Please describe any leadership, civic engagement, or volunteer experience you already have: Please list the names and phone numbers of a minimum of two references that could speak to your participation in this leadership workshop. I need a scholarship: Yes No By submitting this application, I commit to attending all workshop sessions * Yes Date and Time Format: MM/dd/yyyy