Application Form

1. Personal Details

2. Home Address

3. Contact Details

Current Employment details

4. Current Employment Details

Endorsement by and Support from your organisation

Your application must be authorised by your organisation's Chief Executive Officer, Regional Manager, or equivalent

5. Organisation Participation*

* My organisation has given me their full support to participate in the Gippsland Community Leadership Program next year.

CEO / Regional Manager

I, and my organisation, are aware of the time commitment which includes 3 mandatory 2 day/2 night residential sessions, GCLP Launch and Graduation Dinners, annual GCLP Ambassador's Annual Leadership Address, a minimum of 10 program days throughout the year, as well as other events and activities.

YesNo

6. Chief Executive Officer / Regional Director / Manager's details.

Complete the details below and arrange for this person to forward an email stating that you have their support to info@gipps.com.au

7. Previous Employment*

* please begin with most recent.

8. What do you consider to be your highest career achievement to date?

9. Employment Category*

* Australian Bureau of Statistics Employment Category.

Your Community Involvement

10. Volunteer activities

What volunteer activities are you currently involved in? Please list, in order of importance to you, up to four community, civic, professional, business, religious, social, sport and/or other organisations of which you are, or have been, a member.
If none, what future volunteer activities would you like to be involved in?









Our Region - What Gippsland means to you.

11. What are the three most exciting opportunities available to Gippsland?

12. What do you feel needs to be done to support one of these?

13. What do you feel are the three most significant challenges facing Gippsland today?

14. What do you hope to gain from your participation in the Gippsland Community Leadership Program?

15. If selected, what do you consider your major contribution would be to the program?

16. Education and Training*

* please begin with most recent.

17. Other Education Details

Extracurricular / Leadership activities during education

Additional Information

18. Other Details

19. Personal Interests / Hobbies.*

* please provide details

20. How did you first hear about Gippsland Community Leadership Program?

Personal Referees

21. Leadership Performance Referees*

* Please list two persons who are knowledgeable about your leadership performance and potential.

These referees may be contacted by the selection panel.

Time Commitment

Attendance at the Opening, Mid-Year and Closing Residential sessions, the Program Launch, Graduation and GCLP Annual Leadership Address is mandatory.

To graduate from the Gippsland Community Leadership Program, attendance at a minimum of 80% of program sessions is required.

22. GCLP Commitment Acceptance*

* The Gippsland Community Leadership Program requires me to commit to attending 80% or more of the scheduled program and increasing my community involvement upon graduation. If selected I agree that any photographs and written communication produced throughout the program may be published on the internet or published on any other media platform for Program promotion. I acknowledge that any media releases associated with the Community Project I am involved in as part of GCLP will be approved by the Program Director prior to release. I commit to the ongoing support of the program through an continuing association with the GCLP Alumni.

23. Tell us about yourself*

* please provide a 100-200 word biography