Please apply below

Nominated First Name

Nominated Last Name

Nickname (Name known by)

Age

Date of Birth

Nominated Street Address

City

State StateKansasMissouriNebraskaOklahomaColorado

Zip

BusinessOrganization

Title

Business Street Address

Business City

Business Zip

Business State Business StateKansasMissouriNebraskaOklahomaColorado

Email Address

Home Phone

Work Phone

Cell Phone

FAX

In your career, what do you consider your most outstanding achievement so far?

In your life, what do you consider your most outstanding achievement so far?

How long have you been a registered Republican?

Why did you register as a Republican?

Are you a member off any Republican organization(s)? Please specify.

County in which you vote

Kansas Congressional District

Kansas State Senate District

What is the name and address of your Republican County Chairman?

How did you first learn about the Dwight D. Eisenhower Excellence in Public Service Series?

Have you ever been arrested? Have you ever been arrested?Please ChooseYesNo

If yes, please explain:

Please tell us why you feel you would like to be selected for this program and what you hope to contribute to the civic life of our state

Preferred date for personal interview Preferred date for personal interviewPlease ChooseFriday, August 7Saturday, August 8

Dwight D. Eisenhower Pledge Dwight D. Eisenhower Pledge I understand that if selected for the Dwight D. Eisenhower Excellence in Public Service Series, my attendance is mandatory, except in case of emergency. A second absence will result in my being dropped from the program. I pledge that, if selected, I will use what I learn in the Series to actively particpate in the political process, whether as a candidate myself or in support of candidates, or in public service.