Roanoke Electric Cooperative

Co-op Leadership Conference for Couples Application

Below you will find an application for the Young Cooperator's Leadership Conference. As you know, you or your spouse must be an existing member of Roanoke Electric Cooperative in order to attend this exciting event. Please complete the form and submit it by the deadline. Please be sure to note that this retreat is for adults only.

Upon receiving your application, our Leadership Programs judging committee will convene in order to evaluate your application, which will be scored based on both your community involvement and leadership roles you’ve held. If you have any questions, contact us at (252) 209-2259 or toll-free at 1-800-433-2236. We value you as members of Roanoke Electric Cooperative and appreciate the work you do for our community.

Fields marked with a red asterisk * are required.

Husband Information:

*Husband’s Name:
*Husband's Age:
*Husband’s Company or Occupation:

Wife Information:

*Wife’s Name:
*Wife's Age:
*Wife’s Company or Occupation:

Mailing Address:

Address:
City:
State:
Zip:

Contact Information:

*Home Phone Number:
Cell Phone Number:
Work Phone Number:
*Email Address:
*Daytime Telephone Number (M-F between 8 AM & 5 PM):
Best time to call:

Cooperative Affiliations:

Provide the names of cooperatives with which you are doing business or have done business:

Name of Dairy Cooperative:
Name of Farm Supply Cooperative:
Name of Telephone Cooperative:
Name of Electric Cooperative:
Name of Farm Credit Cooperative:
Name of Other Cooperative:

Community Leadership and Development:

Describe Organization Positions Held or Accomplishments and Awards:

*Positions and Awards:

Job-related Information:

Employer and job title or involvement in agriculture or farming, if applicable.

*Job / Agriculture:

To the best of my knowledge the application is accurate and complete.

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