Application

Name *

First

Last

Nickname (Other Name known by)

Age *

Date of Birth *

Nominated Street Address *

Nominated City *

Nominated State *

Nominated Zip Code *

Business/Organization

Title

Business Street Address

Business City

Business State

Business Zip

Email *

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? *

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 *

Options: Friday, Aug. 2, in Wichita, or Saturday, Aug. 3, in Topeka

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. *

Yes
No

Member Login

This site is restricted to members only. If you would like to join our organization, please follow the nomination process.

Be Social With Us!