Application Form

1. Personal Details

2. Contact Details

3. Home Address

4. Postal Address

Your Community Involvement

5. Volunteer Activities?

What volunteer activities are you currently involved in? If none, what future volunteer activities would you like to be involved in?

6. What are your MAIN community interests?

7. Community Organisations

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.

What You Think About Gippsland

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

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

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

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

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

Your employment and education

13. Employment Details

14. Employment Category*

* Australian Bureau of Statistics Employment Category.

15. Previous Employment*

* please begin with most recent.

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

17. Education and Training*

* please begin with most recent.

18. Other Education Details

Extracurricular / Leadership activities during education

Additional Information

19. Other Details

20. Personal Interests / Hobbies.*

* please provide details

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

Program Fees

22. Please select which fee applies to you

23. Fee Acceptance*

* I, and my employer, will pay the costs (individual contribution and employer sponsored fee) as outlined in this document. We also understand that there are other costs such as travel, and some meal and accommodation costs associated with undertaking the Gippsland Community Leadership Program.

24. If selected, I will pay the individual contribution of $550.*

Personal Referees

25. 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.

Commitment to GCLP

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.

26. 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.

Endorsement by and Support from your organisation

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

27. 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

28. 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

29. Tell us about yourself*

* please provide a 100-200 word biography