Leaders in Law Application

Your Name*

First Middle Last

Name as you would like it to appear in print (for awards publication)*

Phonetic spelling of your name (for announcing on stage during awards ceremony)*

For example: "Jay-Cubs" for "Jacobs."

Preferred Email Address*

Additional email to receive event communications (Optional)

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth*

Facebook Profile URL (e.g. http://www.facebook/johndoe)

LinkedIn Profile URL (e.g. http://www.linkedin.com/profileview?id=1234567)

Please upload a headshot. (This may be used in the awards ceremony or publication.)

Max. file size: 15 MB.

Email [email protected] with any issues.

Category*

Position Title*

Company/Affiliation*

Number of employees*

Number of employees you supervise*

Company Product/Service Description*

Education: List most recent first and include Degree, Institution and Year Graduated*

Career History: List most recent and include Start and End Year, Company and Title*

Corporate Board Seats Held: List most recent first and include Year and Corporation*

Officer/board membership in professional organizations: (Include volunteer and career-related organizations) Limit to past 10 years, list most recent first and include Year, Position Held and Organization*

Awards/Honors: What awards/honors have you been most proud to receive? List most recent first and include Year, Award/Honor Name and Awarding Institution*

Professional Accomplishment: What do you consider your most significant professional accomplishment to be?*

What is the key to your success? Is there a specific trait, philosophy or ethic that inspires you?*

Community Service: Please tell us how you give back to the community.*

Impact of Achievements: How have your achievements made a positive difference in your profession, your community, or in society at large?*

Career Support: Who has made a significant impact on your career?*

Summarize in two sentences what you do for a living and what makes you stand out from your peers.*

Surprising fact: What would people be surprised to learn about you?*

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