Application form Leadership WA’s Signature Leadership Program 1 Welcome/Personal details2 Personal details3 Education 4 Employment and experience5 Affiliations6 Payment details We are delighted you are interested in applying for Leadership WA’s Signature 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 Signature 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:• The State Government has mandated COVID-19 vaccinations for many Western Australian workplaces. Various venues we visit throughout the program have been classified under the group 1 or 2 mandates requiring its workforce and visitors to have received a third dose of a COVID-19 vaccine. within a specified time frame.Therefore, in order to fulfill your program attendance criteria we require all participants to be fully vaccinated or have a valid medical exemption. By progressing with the application you acknowledge and agree to the above requirements. • 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 resume (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 90 days. programThe Growing Leaderships Scholarship Program is open to any applicants who are involved in a grain growing enterprise in WA, are based regionally, and have demonstrated grower group involvement as well as community interest and/or leadership.PERSONAL DETAILS:Title*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 Phone (optional)Are you applying for a Growing Leaders Scholarship?*YesNoPlease note, this scholarship is only open to members of the Western Australian grain growing industry.How did you hear about the Growing Leaders Scholarship Program? (you may select more than one)* Direct from GGA Direct from CBH Word of Mouth Social Media We 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. PERSONAL DETAILS:Would you like an Executive Assistant to be CC'd into your emails?*YesNoExecutive Assistant Email* 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 Headshot* Drop files here or Accepted file types: jpg, gif, png, pdf. Where did you hear about us?*ColleagueManagerSearch engineAlumni eventFacebookLinkedInOtherIf other, please specify*SOCIAL MEDIA:LinkedIn 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 Signature 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.Please enter the details of your current study below.*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 Theatre 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 Football Volleyball Marathon running Skiing Tennis Cycling Swimming Baseball Mountain climbing Other If other, please specify*SKILLSPlease list (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/Performing 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) If other, please specify.* 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 AfghanistanÅland 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 How is the organisation you work for/own aligned or involved in the grains industry?*Please provide a brief description of current responsibilities and role within the business*Does your role require you to travel or have periods of peak workloads? (e.g. harvest, seeding)*YesNoLine Manager's Name* First Last Line Manager's Title*Line Manager's Email* Line Manager's Phone*PAST EMPLOYMENTUpload Resume* Drop files here or What do you consider your highest or most significant career achievement to date?*Professional Profile (Biography) – this can be provided as an attachment if necessary*My reasons for applying for the Growing Leaders Scholarship Program are:*My personal vision for the WA grain industry is:*My personal vision for my career/business is:*A few adjectives or phrases that describe me are:*I have a good understanding of what my personal obligations are in participating in the Growing Leaders Scholarship Program, the associated Leadership WA’s Programs and community engagement expectations. I understand that I am required to cover all travel and accommodation costs associated with attending the program events and experiences.*YesNo ACTIVITIES AND ORGANISATIONSPlease list up to five community, civic, professional, business, religious, social, sports and other organisations of which you are, or have been, a member or volunteer indicating any positions of responsibility.*How much time each month do you currently commit to the above organisations or equivalent activities?*What kind of community activities would you like to get into in the future?* PERSONAL LEADERSHIPDescribe your leadership style/s. (approx 250 words)*Tell us about your values. (approx 250 words)*Describe your personal inspirations, leader/s or role model/s and why they are important to you. (approx 250 words)*Please outline any leadership training/courses/subjects you have completed via studies, employment or voluntary work.*Why are you applying for the Signature Leadership Program?*What strengths and experiences do you feel you would bring to the Program and your fellow participants?*Please outline your understanding of experiential learning.*The Leadership WA community has significant potential to lead transformational social change in our world. We would be very interested to know more about the role/s you have in the community. What impact have you made?*We are interested in finding out more about two key community issues you believe are facing Western Australia. The issues you select could be challenges to be addressed and/or opportunities to be realised. What are the two issues and why do you feel they are important? (approx 250 words)*What do you feel needs to be done on the challenges identified above? (approx 250 words)*How will the broader WA community benefit from your successful completion of the Program?*How will your organisation benefit from your successful completion of the Program?*PAYMENTHave you discussed payment with your employer?*YesNoPlease select how payment will be made*My employer will payI will be payingI intend on applying for a scholarship*please note we are referring to the "employer contribution" portion on the payment. Please note scholarships are only available to applicants from not-for-profit organisations.Name of company/person to be invoiced.*I have read and understood the privacy policy and the terms and conditions of Leadership WA.* Agree If unsuccessful I would like Leadership WA to contact me about other opportunities.YesNoTerms & conditions Privacy Policy Code of ConductNameThis field is for validation purposes and should be left unchanged.