APPLICATION FORM
Moremi Initiative for Women’s Leadership in Africa
Engaging, Equipping and Inspiring the Next Generation of African Women Leaders
Confidential Application – Class of 2017
- GENERAL INFORMATION
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Please type or print in ink.
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| PARTICIPANT NAME: | |||||||||
| Surname | First/Given | ||||||||
| DATE OF BIRTH: | |||||||||
| Day | Month | Year | |||||||
| COUNTRY OF ORIGIN: | |||||||||
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SCHOOL/ ORGANIZATION : |
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LEVEL/ JOB TITLE: |
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MAILING ADDRESS: |
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| City | Province/State | Country Postal code | |||||||
| PHONE: | FAX: | ||||||||
| include country and city codes | include country and city codes | ||||||||
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E-MAIL ADDRESS: |
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| OTHER PHONE: | FAX: | ||||||||
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| ADDITIONAL E-MAIL ADDRESS: | |||||||||
| How did you hear about MILEAD Fellows Program?
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| Have you participated in any other Leadership programs? If so, list programs.
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- EDUCATIONAL BACKGROUND
| NAME AND LOCATION OF INSTITUTION | FIELD OF STUDY | DEGREE/ CERTIFICATE | YEAR |
- COMMUNITY SERVICE*Include community, civic, religious, political, or government activities. Please do not include business or professional activities.
| MOST SIGNIFICANT COMMUNITY ACTIVITY | ORGANIZATION | YEAR | ROLE/ RESPONSIBILITY |
- COMMUNITY OR CIVIC AWARDS AND HONORS
| AWARD OR HONORS | ORGANIZATION | DATE |
- FIELDS OF WORK AND AREAS OF INTEREST
Health and Safety
q HIV/AIDS
q Reproductive Health
q Maternal and Child Health
Education
q Education
q Formal / Non-formal Education
q Vocational training
Democracy & Governance
q Civil Society Strengthening
q Conflict Mitigation & Management
Economic Empowerment
q Poverty Reduction/ Income Generation
q Entrepreneurship
q Small/Medium Business Development
Gender Equity and Women’s Rights
q Women’s Rights/ Human Rights
q Social Justice
q Gender-Based/ Child Violence
q Women’s Political participation
q Pan-Africanism / Social Justice
Please list/include other areas that are equally important but not listed:
- EMPLOYMENT
| EMPLOYER | RESPONSIBILITY | START DATE | END DATE | TITLE |
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- PROFESSIONAL or COMMUNITY AFFILIATIONS/ MEMBERSHIPS
| ORGANIZATION | POSITION HELD | DATE |
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- APPLICANT ESSAY
Do not attach a separate page. Please answer the following briefly in the spaces provided.
- What do you consider your most important accomplishment and why? What leadership role did you play?
- What do you consider your highest career or academic achievement to date? Briefly explain.
- What do you think are the three most critical problems confronting women in your community today and what do you think should be done about them?
- Why should you be selected for the MILEAD Program?
- What do you hope to gain from your experience? List and briefly explain your top three expectations in order of importance to you.
- Moremi Initiative is committed to selecting a diverse class of participants that reflects the diversity of the continent in terms of geography, education, class, religion, financial need, or other categories. Also important are diverse political opinions and worldviews. Please briefly characterize how your political views, faith, or other aspects of your “worldview” will contribute to the diversity of the class.
- Is there any additional information that you believe would assist the selection committee in assessing your qualifications? If so, describe briefly.
I have read the above and understand the commitment involved in the MILEAD participation. I affirm that all of the information listed on this application is true. [Please sign with your initials or electronic signature. DO NOT PRINT & SCAN]
Signature of Applicant Date