Application

The application period to become a 2012-2013 KCCI Community Catalyst is now open! All applications will be due on August 13, 2012.

Download 2011-2012 KCCI Community Catalyst Application –

Please fill out this application in its entirety. Application form cannot be saved to return to at a later time, so you may want to prepare your answers to the short-answer questions in advance. If you have questions or concerns filling out the form, please contact Kelsey Primiano at kelsey.primiano@kccitallahassee.com. All applications are due by 5:00PM on August 13, 2012.

There is no fee to become a KCCI catalyst.

2012-2013 KCCI Catalyst Application

Personal
Section 1 Personal Information: The first three fields (Date of Birth, Ethnicity and Gender) are for statistical purposes only.
Date of Birth
Ethnicity
Gender
Name
FirstLast
Home Address
Street AddressAddress Line 2CityState / ProvinceZip / Postal CodeCountry
Work Address
Street AddressAddress Line 2CityState / ProvinceZip / Postal CodeCountry
Primary Phone
Phone format: (###)###-####
Work Phone
Phone format: (###)###-####
Preferred Email
Mail Preference
Employment
Section 2 Employment Information
Present Employer
Hire Date
Job Description
Briefly describe your job responsibilities with particular attention to specific accomplishments.
Education
Section 3 Educational Background
College/University
Degree
From/To
College/University
Degree
From/To
College/University
Degree
From/To
How long have you lived in Tallahassee?
General Information
Section 4 General Information: Please limit answers to space provided.
1. What has been your most important contribution to your community? Why? What role did you play?
2. What have you read that made you change your mind/perspective?
3. In your opinion, what are the top three challenges facing the community?
4. Take one of these challenges and explain how you would address/improve.
5. How do you envision this community in five years? What do you believe your role will be?
6. Please share ideas/best practices from other communities that interest you.
7. Why are you interested in joining the KCCI?
8. Please rate, on a scale from 1-10, your skill in the areas of:
Please rate, on a scale from 1-10, your skill in the areas of:
a. Research
Please enter a value between 1 and 10.
b. Advocacy
c. Communication
d. Business reporting/writing
e. Creativity/Innovation
f. Collaboration
9. Can you dedicate approximately 2 hours per week to a volunteer initiative to help insure its success?
Additional Comments
Community Involvement
Section 5 Community Involvement: Please list, in order of importance to you, three communities, civic, religious, social, athletic or other organizations for which you are, have been, or would like to be, a leader in your community.
Organization 1
Dates of Membership
Leadership Role
Organization 2
Dates of Membership
Leadership Role
Organization 3
Dates of Membership
Leadership Role
If you are not selected as a community catalyst, would you like to be contacted for future involvement with KCCI projects?
References
Section 6 References: Please list up to 3 references.
Name, Address & Title/Company
Contact Phone
Phone format: (###)###-####
Email
Name, Address & Title/Company
Contact Phone
Phone format: (###)###-####
Email
Name, Address & Title/Company
Contact Phone
Phone format: (###)###-####
Email

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2012-2013 KCCI Catalyst Application

Personal

Employment

Education

General Information

8. Please rate, on a scale from 1-10, your skill in the areas of:

Community Involvement

References

KCCI News