2001 - Epsilon State-Louisiana



45720050397BEA DAVIS LEADERSHIP SEMINAR APPLICATIONJune 4-6, 2021DEADLINE: January 15, 2021The purpose of the Bea Davis Leadership Seminar is to train potential leaders for service to Epsilon State and Delta Kappa Gamma. The seminar is held in early June of odd-numbered years, beginning on a Friday afternoon and continuing through breakfast on Sunday. Funding for this special Seminar was made available through a bequest from the estate of Miss Beatrice Davis, a past Louisiana State President and Southeast Regional Director. Requirements: A minimum of three full years in good standing with Epsilon State and evidence of: leadership potential as demonstrated by holding chapter office or involvement in committee work of Delta Kappa Gamma, professional involvement, attendance at an Epsilon State District Meeting or State Convention, state representation. The following persons are not eligible for participation: present or past elected state officers and former international Golden Gift Leadership/Management Seminar participants.Bea Davis Leadership Seminar application process has 3 parts: Application, Recommendation Forms, and Checklist with required signatures. (See information listed below and the attached forms.) A colored picture not greater than 4x6 is required; it may be emailed as an attachment to Part 1 or may be mailed with Parts 2 and 3.Part 1 Application Form Application Form pages 1-3 must be emailed to Kathye Blackburn, State Leadership Development Chairman at kathyeb.dkg@by January 15, 2021.Parts 2 and 3 must be sent by certified mail or scanned then emailed to the following address no later than January 15, 2021:Kathye BlackburnState Leadership Development ChairmanEmail: kathyeb.dkg@Part 2 Recommendation FormsChapter President’s RecommendationProfessional Reference RecommendationPart 3 ChecklistChapter Treasurer’s SignatureApplicant’s SignatureDIRECTIONS: All responses MUST be typed. Answers must be confined to the space provided on this application form; therefore, be concise and precise in completing this form. Be selective in specification of contributions or awards.Name _ Date Initiated LastFirstMIChapterNumber of MembersDistrict Address Street or PO BoxCityZipPhone Email LEADERSHIP POTENTIALHave you held any of the following offices at the CHAPTER LEVEL? (Check all that apply) President Recording Secretary First Vice President Parliamentarian Second Vice President Treasurer Corresponding SecretaryWhich CHAPTER LEVEL committee have you CHAIRED? (Check all that apply) Program Nominations Personal Growth and ServicesRules Professional Affairs Communications Research Scholarships Music Representative World Fellowships Finance Other (Specify) Have you served as DISTRICT DIRECTOR? How many DISTRICT MEETINGS have you attended? Have you ever CHAIRED a committee when your chapter hosted a DISTRICT MEETING? How many times have you participated on the program at a DISTRICT MEETING? How many STATE CONVENTIONS have you attended? Have you participated on a STATE CONVENTION PROGRAM? Have you served on any STATE COMMITTEE?If YES, name the committee(s): Have you received a STATE SCHOLARSHIP? Have you served as the State President, State First Vice President, State Second Vice President, or State Recording Secretary? Have you ever received an INTERNATIONAL GOLDEN GIFT AWARD to participate in the LEADERSHIP MANAGEMENT SEMINAR? How many REGIONAL CONFERENCES have you attended? Were you ever on a REGIONAL CONFERENCE PROGRAM? How many INTERNATIONAL CONVENTIONS have you attended? Were you ever on an INTERNATIONAL CONVENTION PROGRAM? Have you served on an INTERNATIONAL COMMITTEE? Have you received an INTERNATIONAL SCHOLARSHIP?374650179070In three words, name the CHARACTERISTICS that best describe you. , ,00In three words, name the CHARACTERISTICS that best describe you. , ,PROFESSIONAL INVOLVEMENTIndicate facts about the highest earned degree which you hold:Degree: Year Earned: University/College: Areas of Certification: 49085516065500Current Position Employer/Location (If retired, list last.)__________________________________________________________________ Your MAJOR professional responsibility List the Membership and Offices held in MAJOR PROFESSIONAL ORGANIZATION(S) other than the SOCIETY. (Begin with most recent. Do not use acronyms or initials.)DatesOrganizationInvolvement49085517145000490855154305004908551543050049085515430500COMMUNITY INVOLVEMENTList the Membership and Offices held in COMMUNITY ORGANIZATION(S) other than the SOCIETY. (Begin with most recent. Do not use acronyms or initials.)DatesOrganizationInvolvement49085517272000490855154305004908551543050049085515240000GENERALIn what ways would you be willing to share with other members of Epsilon State, your District, and your Chapter the skills acquired in the BEATRICE DAVIS LEADERSHIP SEMINAR?457200173355004572004356100045720069786500How will you use skills acquired in the BEATRICE DAVIS LEADERSHIP SEMINAR in your professional career?457200171450004572004337050045720069596000Why do you want to participate in the BEATRICE DAVIS LEADERSHIP SEMINAR?457200171450004572004356100045720069596000DEADLINE FOR APPLICATIONAll Parts of this application must be COMPLETED and EMAILED no later than January 15, 2021.FOR OFFICE USE ONLYDate Received: ?Dr.?MissCHAPTER PRESIDENT RECOMMENDATION FORM2021 BEATRICE DAVIS LEADERSHIP SEMINARThe Delta Kappa Gamma Society International Louisiana State Organization(Type or Print)?Mrs.(Applicant's Name)?Ms.(Last)(First)(MI)?Dr.?Miss?Mrs. (Reference Name)?Ms.(Last)(First)(MI) (Reference Address) Street or PO Box64770017399000CityStateZip( ) ( ) Business PhoneHome PhoneHow long have you known the applicant and in what capacity?9144002012950091440018288000From your point of view, what are the applicant's principle strengths?914400201295009144001828800095250018288000What has the applicant done to evidence leadership potential or professional competency to be endorsed for this award? (Specifics)914400172085009144001828800095250018288000Chapter President Recommendation (Continued)Rate this applicant: Outstanding Superior Good Average Not able to determine (Explain)45720020129500In addition to the information indicated above, any additional comments that you might share to assist the committee in the selection process would be appreciated.4572002012950045720018288000457200182880004572001828800045720018288000CHAPTER PRESIDENT: (Or Immediate Past President if current President is applying.)137160023050500(Print Name)137160020129500(Signature)137160020129500(Date)PLEASE RETURN COMPLETED FORM TO APPLICANT IN THE SELF-ADDRESSED STAMPED ENVELOPE NO LATER THAN THANK YOU FOR YOUR ASSISTANCEFOR OFFICE USE ONLYPostmark/Email Date: ?Dr.?MissPROFESSIONAL REFERENCE RECOMMENDATION2021 BEATRICE LEADERSHIP SEMINARThe Delta Kappa Gamma Society International Louisiana State Organization(Type or Print)?Mrs. (Applicant's Name)?Ms.(Last)(First)(MI)?Dr.?Miss?Mrs. (Reference Name)?Ms.(Last)(First)(MI) (Reference Address) Street or PO Box68580020129500CityStateZip( ) ( ) Business PhoneHome PhoneHow long have you known the applicant and in what capacity?9144002012950091440018288000From your point of view, what are the applicant's principle strengths?914400201295009144001828800095250018288000What has the applicant done to evidence leadership potential or professional competency to be endorsed for this award? (Specifics)914400172085009144001828800095250018288000Professional Reference Recommendation (Continued)Rate this applicant: Outstanding Superior Good Average Not able to determine (Explain)45720020129500In addition to the information indicated above, any additional comments that you might share to assist the committee in the selection process would be appreciated.457200201295004572001828800045720018288000457200182880006,Professional Referent’s Signature137160020129500(Print Name)137160020129500(Signature)137160020129500(Date)PLEASE RETURN COMPLETED FORM TO APPLICANT IN THE SELF-ADDRESSED STAMPED ENVELOPE NO LATER THAN .THANK YOU FOR YOUR ASSISTANCEFOR OFFICE USE ONLYPostmark/Email Date: 2021 BEATRICE DAVIS LEADERSHIP SEMINARAPPLICATION CHECKLIST(Submit with application)The FOLLOWING ITEMS ARE REQUIRED for application to be considered for the BEATRICE DAVIS LEADERSHIP SEMINAR: 1. Photograph (Send as email attachment to Part 1: Application Forms, Pages 1-3 or mail a picture no larger than 4 x 6 with Parts 2 & 3)May be used for publicity purposes.Is not considered part of the applicant’s papers which are used by the committee in selecting recipients. 2. Email Part 1: Application Forms, Pages 1-3 to kathyeb.dkg@ no later than January 15, 2021. 3. Mail Parts 2 & 3 (items A-D below) by certified mail to Kathye Blackburn, State Leadership Development Chairman, 2506 Fieldwood Circle, Bossier City, LA 71111 or scan Parts 2 & 3 (items A-D below) then email kathyeb.dkg@ no later than January 15, 2021. A. Chapter President Recommendation B. Professional Reference Recommendation C. Verification of Dues Payment (Chapter Treasurer Signature) D. This Application Checklist Complete information below:RECOMMENDATIONS BY:Chapter President Recommendation (or Immediate Past President, if current president is the applicant)?Dr.?Miss?Mrs ?Ms.(Last)(First)(MI)70104018161000Street or PO BoxCityStateZipProfessional Reference Recommendation?Dr.?Miss?Mrs ?Ms.(Last)(First)(MI)70104018034000Street or PO BoxCityStateZipTreasurer Certification of Required Membership Status and Payment of Current Dues91440016954500419671516954500Signature of Chapter TreasurerDateApplicant’s CertificationI certify that the information provided in this application is correct and I have met the specified requirements to apply.91376517272000419671517272000Signature of ApplicantDate ................
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