espnWGlobal Sports Mentoring Program
APPLICATION FORM

NOTE: When using Acronyms, please provide the complete name for organization, company, institution e.t.c.

Personal Information

  1. Nominee's Full Name, as it appears on his/her passport

Prefix:

Full Name :

First Name (s):

Middle Name (s):

Surname (s):

  1. Date of Birth: Month Date Year
  2. Age:
  3. City of Birth:
  4. Country of Birth:
  5. Country of Citizenship:
  6. Country of Residence:
  7. Medical, Physical, Dietary or other Personal Considerations:
  1. Home Address, Telephone and E-mail

Home address:

Telephone:

Fax:

Mobile:

Email:

Professional Information

  1. Current Position and Title:
  2. Position Description Provide a description of your role in the workplace. Provide information to show that you hold a position of influence with significant responsibilities:
  1. Place of Employment and Complete Address:
  2. Place of Employment DescriptionProvide a description of your workplace. Include information on the organization's sector (private, public, non-governmental), number of employees, annual budget, and annual revenue. Additional details such as organization mission, relevance to the sports sphere, and website link are welcome:
  1. Work Experience, Including Previous Positions and Titles
  1. Accomplishments: Describe your accomplishments and contributions to society, particularly in the context of sports and female empowerment that exhibits characteristics of leadership, confidence, and commitment.

Year / Accomplishments
  1. Skills: Provide a list of skills that may be personal, executive, and technical strengths (e.g. multi-lingualism, proven athleticism, event coordination capability, technology abilities, communication and management skills).
  1. Personal Interest(s): Describe your interests and endeavors outside of work (e.g. hobbies, volunteer, other activities).
  1. Education, Academic and Professional Training, including degrees earned, fields of specialization, and year obtained:

Year
(from – to) / Education / Institute
  1. Active Professional Memberships:

Position / Organization
  1. Publications (no more than ten):

Year / Type / Title / Publisher
  1. Previous Travel and Study or Research Experience in the United States, including dates and indication as to whether such travel was supported by U.S. Government Funds:
  1. Family Residing in the United States: Please list any immediate family members who are currently residing in the United States, including city and state:
  1. Evidence of Fluency in Written or Oral English (e.g. personal interview, test score, etc.):
  1. Statementof Interest(s)(no more than 3,500 characters each):

(1)Please provide a description of what you hope to gain from the mentorship experience and how you will maximize the opportunity. Please also share how you will show your commitment to the program and willingness to share and amplify the experience by helping others succeed.

INSTRUCTIONS TO SUBMIT YOUR APPLICATION

Applicants should submit an application for this program by e-mail ().
Emails should include your name and the program applied on the subject.
The application deadline is March 1, 2013.

Applications must include the following documents:

  1. Application Form (including the statement of interests typed on this form).
  2. Current resume/CV.
  3. Scanned passport biodata page.