Please type or print clearly.  You may duplicate this form
  Name: __________________________________________________________________________
Home Address: ___________________________________________________________________
                         ___________________________________________________________________
Home Phone: ________________________Home Fax Number:_______________________
Work Address: ____________________________________________________________________
       _____________________________________________________________________________
Work Phone: ________________________Work Fax Number:_______________________

Where do you prefer to receive IWIL mailings?     __ Home        __ Work
Cell Phone: _____________________E-Mail Address:____________________________

EDUCATIONAL BACKGROUND
Begin with high school and include all post-secondary educational experiences, even if degrees were not completed.

_________________________________
_________________________________
_________________________________

_____________________
_____________________
_____________________

_________________________
_________________________
_________________________

Employer Name: ________________________________________       Phone:   _____________
  Address: ______________________________________
                 ______________________________________
 Title/Responsibility:_______________________________ 

Employer Name: __________________________________________       Phone:   _____________
  Address: ______________________________________ 
                 ______________________________________
 Title/Responsibility:________________________________

Employer Name: ____________________________________________       Phone:   _____________
  Address: ______________________________________ 
                 ______________________________________
 Title/Responsibility:________________________________

Employer Name: ______________________________________________      Phone:   _____________
  Address: ______________________________________ 
                 ______________________________________
 Title/Responsibility:________________________________

PROFESSIONAL/UNION ORGANIZATIONS
List any professional/union organizations you have belonged to over the past ten years, listing the most recent first.
State the name of the organization, its purpose, years of membership and any leadership positions you have held.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

CIVIC/COMMUNITY/RELIGIOUS ORGANIZATIONS
List any social, philanthropic, civic, athletic, and/or religious organizations that you have belonged to over the past ten years.  State the name of the organization, its purpose, years of membership and any leadership positions that you have held.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

AWARDS AND RECOGNITIONS
List any non-academic awards and/or recognitions that you have received in the past ten years.
Explain the nature of the award and provide dates.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

ROLE MODELS: Identify the three individuals you most admire and briefly explain your choices.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

ESSAY: On an attached page please explain why you should be selected for the IWIL Training Program. For example, how will you benefit from the program? What do you have to offer to the program and the Democratic Party?
Please limit your statement to one typewritten page.

Did you vote in the last two Democratic Primary Elections?    __ Yes        __ No
If you did not vote, please explain:________________________________________________________________
__________________________________________________________________________________________

Signature:______________________________    Signature:_________________________________
Title:__________________________________    Title:_____________________________________
Date:________________________                       Date:________________________

REFERENCES
Please list two individuals who can attest to your qualifications for acceptance into the training program.

Name: _________________________________ Title: __________________________________ Address: _______________________________                _______________________________ Phone: _________________________________

Name: ________________________________ Title: __________________________________ Address: _______________________________                _______________________________ Phone: _________________________________