Confidential Application for 2013 ProgramReturn COMPLETED application to:Amanda Hennessy, Executive OfficerLeadership Great South CoastPO Box 51, Port Fairy, VIC 3284

OR EmailAmanda Hennessy, Executive Officerinfo@leadershipgreatsouthcoast.org.au

NO LATER THAN FRIDAY, 26 OCTOBER 2012.

This form can either be completed by hand, as a word document (which can then be printed or emailed) or as a PDF form (which can then be printed or emailed). Please note: You can only use the PDF Form (to be emailed) if you have the program Acrobat Professional. If you require assistance to complete the form, please contact LGSC Executive Officer Amanda Hennessy on 0408 627 066.

Personal DataFirst Name:

Middle Name:

Surname:

Preferred Name:

Age: Date of Birth:

Male Female

Home Address:

City/Town: Postcode:

Personal Mobile: Home Phone:

Preferred Email contact:

1

EmploymentPresent Employer/Organisations:

Title/Position:

Business Address:

Business Postal Address:

City/Town: Postcode:

Phone (BH): Mobile:

Date Commenced:

Statement of Employer supportIf you have employment that may conflict with Program Days, please indicate your employers support. The candidate has my full support to participate in the Leadership Great South Coast Program.

I am aware of the time commitment and organisational financial commitment which will be due once place offers are made in November 2012.*

Employer or Sponsor Name:

Title:

Organisation:

Signature: Date:

Executive/CEO support

Signature: Date:

ScholarshipsPlease indicate if you wish to apply for a scholarship place in the 2013 Program. Information is available on request.

2

Yes No

PersonalWhy do you want to be a participant of Leadership Great South Coast Program?

What strengths and experiences do you bring to Leadership Great South Coast Program?

What do you hope you and your community will gain from your participationin Leadership Great South Coast Program?

3

Activities and Organisations

What are your current major community/volunteerism interests?

What kind of volunteer activities would you like to pursue in the future?

4

Community Awareness

What do you feel are the two most significant issues facing the GreatSouth Coast region?

What do you think needs to be done on one of these issues?

5

Community Awareness Cont.

What are the two most exciting opportunities available to the Great South Coast region?

What do you feel needs to be done to develop one of these?

6

PLEASE INCLUDE WITH THIS APPLICATION YOUR RESUME WHICH OUTLINES THE MOST IMPORTANT ASPECTS OF YOUR CAREER AND/OR EDUCATION. PLEASE FEEL FREE TO HIGHLIGHT ANY ELEMENTS WHICH YOU FEEL ARE NOT COVERED BY YOUR ANSWERS IN THE APPLICATION FORM WHICH ARE IMPORTANT TO YOU. *

* The selection panel reserve the right to request copies of qualifications listed on your CV. Scripts may also be requested.

Resume included:

Yes No

ParticipationGraduation from the Leadership Great South Coast Program requiresattendance of a minimum of 80% of Program Days.80% attendance includes mandatory attendance at the Opening and Closing Retreats.

ReferencesPlease list two (2) persons other than your CEO/Sponsor who are knowledgeable about your leadership performance and potential.

Name:

Title:

Organisation: Phone:

Name:

Title:

Organisation: Phone:

7

Personal CommitmentI UNDERSTAND THE GOALS AND TIME COMMITMENTS OF THE LEADERSHIP GREAT SOUTH COAST PROGRAM. IF SELECTED, I WILL DEVOTE THE REQUIRED TIME AND PAY THE PERSONAL CONTRIBUTION UPON REQUEST.

I UNDERSTAND THAT I AM COMMITTING MYSELF TO INCREASED COMMUNITY INVOLVEMENT UPON GRADUATION AND ONGOING CONNECTION TO LEADERSHIP GREAT SOUTH COAST THROUGH THE ALUMNI PROGRAM.

Applicant Name:

Signature: Date:

Financial ContributionsParticipants and their organisations are asked to contribute to Leadership Great South Coast in order to offset the costs of running the program. The contribution amounts are set at $3000 + GST.The Leadership Great South Coast Steering Committee is committed to the selection of participants with diverse backgrounds, and also to the principle that no economic barrier should prevent any suitable individual or organisation from participating in the leadership program. Should these amounts pose a difficulty the Chair of the Steering Committee would be pleased to discuss the circumstances confidentially. Every effort will be made to find scholarships to ensure a diverse range of participants although no guarantee can be given that this will be successful.Leadership Great South Coast is also a proud beneficiary of the Regional Leadership Development Fund, provided by the Victorian Government.

* The proportion of contribution from employer and employee can be negotiated with Leadership GSC.

8