ENTREPRENEURS for SOCIAL CHANGE:

Training Application Form

16 to 22 October 2014 in Torino, Italy

A partnership between United Nations Alliance of Civilizations, Fondazione CRT and the Italian Government via its Ministry of Foreign Affairs

APPLICATION DEADLINE: 11:59 PM, New York time, 14 July 2014

PART A: Applicant’s profile
First name (given name) EXACTLY AS IT APPEARS IN YOUR PASSPORT
E.g. John
Last name (family name/surname) EXACTLY AS IT APPEARS IN YOUR PASSPORT
E.g. SMITH
Gender
Date of birth (DD/MM/YYYY)
Country of birth
Current country of residence
Current nationality
Passport number
Countrywhich issued passport
Date of issuance of passport (format DD/MM/YYYY)
Expiry date of passport (format DD/MM/YYYY)
Mailing address (Must be valid until May 2015. If not, provide a permanent mailing address)
Phone number (incl. country code)
E-mail address
What is your level of English? /  Excellent  Good  Fair Poor
What is your current main occupation? (e.g. student, intern, professional, looking for employment, etc.) Please provide more details (e.g. sector of employment, etc.)
Did you graduate from university? If so, from which university? In what sector?
Are you a member of a civil society / non governmental organization? /  Yes
 No
Applicant’s organization name, if applicable
Applicant’s position/title in this organization, if applicable
Applicant organization’s mandate (the goal and objectives of the organization), if applicable
Website of applicant’s organization, if applicable
PART B: Information about the social enterprise
Q1: Is the social enterprise you will describe below already existing?
If yes, please describe its main features (year it started its activities, main projects, main source of income, etc.)
If not, please describe the idea of the social enterprise you have in mind and what steps you have already undertaken to start it.
Q2: What are the overall objectives of your social enterprise? What is the social change that you want to generate?
Response needs to include a maximum of 150 words.
Q3: What kind of issue(s) is your social enterprise trying to address?
Response needs to include a maximum of 200 words.
Q4: Who are you targeting with your social enterprise? Who are/will be your main clients?
Response needs to include a maximum of 100 words.
Q5: Describe the activities you are implementing or will be implementing through your social enterprise to address the stated issue(s) and reach your objective(s). How will these activities help you reach the objective(s)?
Response needs to include a maximum of 350 words.
Q6: How does your social enterprise contribute to positive social change in a specific community?
Response needs to include a maximum of 350 words.
Q7: How will your social enterprise generate employment for you and/or members of your community?
Response needs to include a maximum of 200 words.
Q8: How will your social enterprise generate income or revenues and ensure sustainability, both in terms of employment and social change?
Response needs to include a maximum of 200 words.
Q9: Present the main features of your business plan and the way you intend to further develop your social enterprise.
Q10: Describe strength and weaknesses of your social enterprise.
Q11: Do you have partners in this social enterprise? Who are they? What is their role?
Response needs to include a maximum of 100 words.
Q12: What type of skills and knowledge do you need to receive for this social enterprise to be launched/implemented with success?
Response needs to include a maximum of 150 words.
Q13: How does your past experience, motivations and aspirations positioning you to successfully launch and implement this social enterprise?
Response needs to include a maximum of 100 words.
Q14: If you are a member of an organization (as per information above), what would be the involvement of this organization in the social enterprise proposed here?
Q15: Should we know something else about you and your social enterprise?
PART C: Other Questions and Checklist
If you were selected to be part of this program, from which city would you have to depart from to travel to Italy (what is the city with an international airport that is the nearest to where you will be on 15 October 2014)? / City:
Country:
Do you have any dietary restrictions? /  Yes
If yes, which? ______
No
Do you have one of the following food preferences? / Kosher
 Halal
 Vegetarian
Please provide emergency contact name, number and email address / Name and relationship to the applicant:
Telephone number:
Email:
Did you save the application form in Word Format (.doc)or Rich Text Format (.rtf)? Please do not PDF the application form. /  Yes
No
Did you include ascanof the identification page of passport? /  Yes
No
Did you attach your resume/CV? (in English, 3 pages maximum) /  Yes
No
PART D: Attestation
I attest that the information provided above is true and complete. I recognize and accept that providing false, misleading, or intentionally incomplete information will provoke immediate refusal of my application. /  Yes
No
Date (DD/MM/YYYY)

Submit your complete application package to by 11:59 PM, New York time, 14 July 2014.

Application packages sent by fax, regular mail or express mail will not be accepted.

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