Australia Awards Women’s Leadership Initiative
Tier 2 Leadership and Mentoring Program – Cohort 2 (July 2018)
Application Form
1.Personal details
Title Choose an item.First name: Click or tap here to enter text. Last / surname: Click or tap here to enter text.
Preferred name: Click or tap here to enter text.
Date of birthClick or tap here to enter text.Country of Birth:Click or tap here to enter text.
Citizenship (if different from country of birth):Click or tap here to enter text.
First language:Click or tap here to enter text.IELTS score:Click or tap here to enter text.
2.Study details
Educational institution at which you are currently enrolled:Click or tap here to enter text.
Campus location:Click or tap here to enter text.
Study awardChoose an item.Course (Field of study):Click or tap here to enter text. Enrolment status: Choose an item.
Expected completion date:Click or tap to enter a date.
Student Contact Officer name:Click or tap here to enter text. Student Contact Officer phone: Click or tap here to enter text.
Student Contact Officer email: Click or tap here to enter text.
Under your current Award, have you been subject to any academic performance issues, including being required to repeat courses/ examinations or undertake supplementary assessments? Yes ☐No☐
If yes, please provide further details. Click or tap here to enter text.
3.Contact details
Home phone:Click or tap here to enter text.Mobile: Click or tap here to enter text.Skype: Click or tap here to enter text.
Email:Click or tap here to enter text.
Australian Address: Click or tap here to enter text.
Home Country Address: Click or tap here to enter text.
4.Leadership responsibilities and major achievements
Briefly describe any leadership responsibilities that you have undertaken. What learning did you gain from your experience(s)?:
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Please describe any major achievements associated with your industry or community experience (paid or unpaid). This can include awards or scholarships:
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5.Employment history (please complete this section OR attached a current CV with your application).
☐CV attached.
OR please complete the following:
Recent Employment
Position:Click or tap here to enter text.
Organisation:Click or tap here to enter text.Length of time in this position:Click or tap here to enter text.
Responsibilities:
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Previous Relevant Experience
Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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Position:Click or tap here to enter text.
Organisation:Click or tap here to enter text.Length of time in this position:Click or tap here to enter text.
Responsibilities:
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6.Community involvement
Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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Position:Click or tap here to enter text.
Organisation: Click or tap here to enter text.Length of time in this position: Click or tap here to enter text.
Responsibilities:
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7.Education and other relevantexperience(note: there are no prior education requirements needed to undertake the program)
Education
Qualification/Level achieved: Click or tap here to enter text.Educational institution:Click or tap here to enter text.
Year completed:Click or tap here to enter text.
Leadership Programs
Program name:Click or tap here to enter text.
Organisation:Click or tap here to enter text.Year completed:Click or tap here to enter text.
8.Motivation and Background
What are the particular issues affecting your community or country that would benefit from stronger leadership?
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Why do you want to undertake this leadership development program?
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What impact do you feel you have now as a leader?
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What impact do you expect to have on gender equality in your community or country as a result of your participation in this leadership development program?
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What specific issue would you like to make a difference to (in your home country or in Australia) over the next 18 months?
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What skills do you hope to gain from WLI to help you with this?
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9.Publicity
How did you hear about the WLI?:Click or tap here to enter text.
☐ Please attach a recent portrait photo (jpeg file) as part of your application.
10.Passport details
Please scan and attach a copy of your passport photo and biodata page
11.Referee Details
Please provide contact details of two referees who can attest to your leadership experience or abilities
Referee # 1
Name:Click or tap here to enter text.
Organisation:Click or tap here to enter text.
Relationship:Click or tap here to enter text.
Phone:Click or tap here to enter text.
Email: Click or tap here to enter text.
Referee # 2
Name: Click or tap here to enter text.
Organisation: Click or tap here to enter text.
Relationship: Click or tap here to enter text.
Phone: Click or tap here to enter text.
Email: Click or tap here to enter text.
12.Health
Do you have any medical conditions/disabilities that may impact your involvement in any specific type of activity? If so, please provide details, including any special assistance required.
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13.Agreement – Please read and indicate your agreement to the following terms
The WLI requires up to 15 days’ face-to-face contact over a 12-month period (with some flexible learning modules will be delivered in between sessions).
Are you able to commit to all sessions and flexible learning modules including intensive residential components that will require travel to other parts of Australia? / Yes ☐No☐Have you advised your family that this program requires participants to be away for extended periods of time? / Yes ☐No☐
Do you agree for the WLI to use the information in your application for the purposes of selection for the WLI and matching with academics, mentors and internship providers (this may include forwarding the information to a third party or potential provider)? / Yes ☐No☐
Do you agree to publicise and promote your positive experiences with the WLI throughout the course of the program and into the future (please note that this may require engagement with media as a part of the program curriculum)? / Yes ☐No☐
Do you consent to WLI staffing discussing your application with your university student contact officer, referees, training providers, mentors, internship workplace, or any other agency or individual associated with WLI? / Yes ☐No☐
I declare that the information provided in this form is complete and correct
Name:Click or tap here to enter text.
Signature:
Date:Click or tap to enter a date.
Applications close on Friday 18 May 2018
Please email this completed application form and attachments (see below) to: by 5:00pm Friday 18May 2018. Include the words ‘Application – July 2018’ in the subject heading.Please ensure that you have completed all required fields and attached documentation as requested, as incomplete applications cannot be considered.
Application checklist:
☐ All questions answered
☐ Portrait photo attached
☐ Passport photo/ biodata page attached
☐ CV attached (if not completing section 5)
The Women’s Leadership Initiative is implemented by Cardno on behalf of the Australian Government