Application form Leadership WA’s Rising Leadership Program 1 Welcome/Personal details 2 Personal details3 Social media4 Education5 Employment and experience6 Personal leadership7 Payment We are delighted you are interested in applying for Leadership WA’s Rising Leadership Program. Entry to the Program is competitive. You will be contacted within 4 weeks of submitting your application form to arrange an interview. All applications are then assessed by a selection panel and you will be advised of the outcome of your application once the selection process has been completed. During the selection process, we aim to make the Program cohort a diverse mix of backgrounds, industries, occupations, and experience. This is to ensure the cohort has a wide diversity of thought, which makes for a more rewarding experience for all participants. A limited number of full or partial scholarships may be available, thanks to the generosity of donors to the Leadership WA Foundation. Your assessment of suitability for the Rising Program is not affected by any request for scholarship support. Alternatively, submitting your application early may create the opportunity for an early offer of a place so you may then be able to source your own funding support, if required. WHEN APPLYING, PLEASE NOTE:• All applications are confidential. • All questions must be completed in full and the declaration must be signed. • Individuals may nominate themselves but employed applicants must have the full support of their employer to participate. If you are self-employed, you can support your own application.• You are requested to upload a current headshot (as .jpeg or .gif file) and professional profile / Bio (as Word DOC/DOCX or PDF file) as part of this application. Files must be uploaded prior to submitting the form. (NB: File sizes must not exceed 400kb)• You can save and continue this form by clicking the link at the bottom of the page. A unique link will be sent to your email. Please note this link will only be active for 120 days. • COVID-19 Safety: Leadership WA is highly committed to keeping our people, participants, stakeholders and communities as physically and psychologically safe as possible. Program Participants, Contractors, Alumni, Visitors, Volunteers or other stakeholders engaged in our business are requested (but not mandated) to have up-to-date vaccinations against COVID-19. programYearWhat intake are you applying for?*JuneAre you applying for a Leadership WA Aboriginal Scholarship?*YesNoTo apply for the Aboriginal Regional Scholarship you must identify as Aboriginal and be based or undertaking work in Regional Western Australia. Preference is given to applicants from Not for Profit Organisations or Small Businesses.Are you applying for a Mt Burdett Foundation Scholarship?*YesNoTo apply for the Mt Burdett Foundation Scholarship you must: •Living and working anywhere in regional Western Australia•Early - Mid level in your career•Passionate about creating a positive impact and difference where you live•Keen to build your leadership skills and put them into practice for your communityPERSONAL DETAILSTitle*TitleMrMissMsMrsDrAssociate ProfessorProfessorName* First Last Email* This will be how we send your Program information and acceptance letter. As some work domains may reject our emails as part of their security measures, we recommend a personal address. This email will act as a unique identifier in the Leadership WA database.Phone*Work PhoneWe highly recommend saving your Application at this point. The form can take 20 minutes to complete and by saving now you’ll be able to come back and complete the Application with additional information as needed. The link will be active for 90 days. Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of Birth* Date Format: DD slash MM slash YYYY Gender*FemaleMaleOtherIf other, please specify*What do you identify as your cultural background?*If multiple please separate with a comma (,)Do you identify as Aboriginal Australian and/or Torres Strait Islander?*YesNoUpload Resume*Accepted file types: pdf.Please upload a PDF version of your resume Upload Headshot*Accepted file types: jpg, gif, png, pdf.Where did you hear about us?*ColleagueManagerSearch engineAlumni eventFacebookLinkedInOtherIf other, please specify* SOCIAL MEDIALinkedIn URLProfessional Facebook URLProfessional Twitter URL EDUCATIONAre you currently studying?*YesNoI have checked the dates of the program and am confident my formal study will not affect my participation in the Rising Leadership Program.* Yes Due to the commitment required for our programs it is not recommended to be engaged in formal study while on a program with Leadership WA. However, participants may be able to accommodate both. We recommend you check the dates of the program and make sure your formal study workload will not lessen your ability to fully participate in the program. If you would like to speak to the Leadership Development Manager about this, please call us on (08) 6381 6700.Highest level of education*Doctoral degreeMaster's degreePost Graduate Certificate/DiplomaBachelor's DegreeAssociate DegreeAdvanced DiplomaDiplomaCertificateHigh School GraduateDid not GraduateInstitutionYear completed/expected completionPlease enter a number from 1950 to 2050.Please enter your hobbies and interests Gardening Baking Journaling Fencing Theater Yoga Languages Boardgames Creating and organising a book club Networking events Local meetups Volunteering at a charity centre Public speaking Exploring other cultures Dancing Camping Playing a musical instrument Reading Writing Sketching Photography Design Blog writing Painting Basketball Football Volleyball Marathon running Skiing Tennis Cycling Swimming Baseball Mountain climbing EMPLOYMENT AND EXPERIENCEName of organisation you are employed by*Organisation is a*Commercial BusinessGovernment DepartmentNot-For-Profit OrganisationSole TraderCurrent position title*Work Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Line Manager's Name* First Last Line Manager's Title*Line Manager's Email* Line Manager's Phone*A critical consideration for the Mt Burdett Foundation and Leadership WA is how you will demonstrate that your participation in this program will help you make a marked difference in your community? ie Tell us what you will commit to doing? How will this have a lasting impact in your community?*What inspires you about your regional community and why?*Please attach a brief letter from a member of your community who will provide a character reference to support your application. It needs to include how they know you and what they see as your current and/or potential contribution(s) to your community.*What do you consider your highest or most significant career achievement to date?*Please describe the structure, size and scope of the team you lead? This can be direct reports or a project team. If you don’t currently lead a team, that is fine, please help us understand in what way you are leading other people and will be able to apply the learning as you go through the program.*SKILLSList (multiple choice) your skills* Administration & Office Support Advertising & Media Agriculture Audit and Risk Banking & Financial Services Board Experience Call Centre & Customer Service Coaching/Mentoring Communications/PR/Marketing Community Engagement Community Services Construction Consulting & Strategy Creative/Preforming Arts Data Design & Architecture Digital/Cybersecurity Education & Training Engineering Environment & Conservation Event Management Finance & Accounting Fundraising/Sponsorship & Grants General Management Governance Government & Defence Healthcare & Medical Hospitality & Tourism Human Resources Industrial Relations IT/Information & Communication Technology Insurance Legal Manufacturing Mining/Resources & Energy Occupational Safety and Health Organisational Development Policy and Legislation Project Management Real Estate & Property Retail & Consumer Products Sales Science & Technology Small/Own Business Management Sport & Recreation Stakeholder Engagement Strategic Planning Tendering Trades & Services Transport & Logistics Other (please specify below) Please include Skills you would use in your workplace and outside your place of work ( e.g in volunteering roles)If other, please specify* PERSONAL LEADERSHIPHow will you apply your leadership learning back to your own community to create a marked difference?*What do you consider your highest or most significant leadership achievement to date?*How would you describe your leadership style/s?*What are your key values and why? (approx. 250 words)*Who inspires you as a leader or role model and why? (approx. 250 words)*What skills or knowledge do you think leaders need to develop or know for the future? (approx. 250 words)*What is it about your desire to improve your leadership that makes you want to participate in this program? (approx. 250 words)*Please outline any leadership training/courses/subjects you have completed via studies, employment or voluntary work.*What were the specific learning outcomes/tools/frameworks you covered in the above?* PAYMENTHave you discussed payment with your employer?*YesNoHow will payment be made?My employer will PayI will be payingI intend on applying for a scholarshipI am applying for the Aboriginal Regional ScholarshipI am applying for the Wheatbelt Aboriginal Leaders Scholarship?I am applying for the Mount Burdett Scholarship*please note we are referring to the "employer contribution" portion on the payment. Which WA Region do you work in?*How do you intend to practically apply learnings from the Program to benefit your organisation and surrounding regional community?’*Demonstrate how you will share the learnings from the Program to your organisation and your regional community(Minimum of 3 activities within 12 months of completion of the program)?*Name of company/person to be invoiced.** I understand that Leadership WA may contact my manager to discuss my application If unsuccessful I would like Leadership WA to contact me about other opportunities* Yes No * I have read and understood the privacy policy and the terms and conditions of Leadership WA Terms & condtions Privacy Policy Code of ConductPhoneThis field is for validation purposes and should be left unchanged.