Australia Awards FellowshipsPapua New GuineaCourse: Certificate IV in Entrepreneurship and New Venture Creation

Application Form for Private Sector and Civil Society Applicants

1. PERSONAL INFORMATION

Title Mr. Mrs. Ms. Dr. Other_____

First Name / Given Name

Surname / Family Name

Date of Birth (dd/mm/yyyy)

Place of Birth (State/Province)

Current Age

Sex

Province of Origin

Province of Residence

Do you have a passport? Yes No

If yes, provide passport number Issue date / /

Expiry date / /

Are you a citizen of PNG? Yes No

Do you hold a passport of another country?

YesCountry Name: No

Do you have a birth certificate? Yes No

2. CONTACT DETAILS

If you are not contactable, your application may not be considered

Postal Address

Town / City Postal Code

Province

Home Phone Number/s

2. CONTACT DETAILS

Work Phone Number/s

Mobile Phone Numbers/s

Fax Number/s

Email

3. EMERGENCY CONTACT DETAILS

First Name / Given Name

Surname / Family Name

Relationship to you

Home Phone Number/s

Work Phone Number/s

Mobile Phone Number/s

Email

4. CURRENT EMPLOYMENT

Position title

Briefly describe your role in no more than three sentences

How many years have you been working in your current profession, and with this business/organisation?(include some detail of current and previous roles)

5. BUSINESS DETAILS

Name of Business

Do you own this business? Yes No

Is your business registered with Investment Promotion Authority (IPA)? Please attach a copy of your IPA registration

Yes No

How long has this business been in operation? Please attach a copy of your business profile

Briefly describe in one paragraph the business activities

6. CURRENT MANAGER/SUPERVISOR’S DETAILS

Position title

Name

Email

Phone Number/s

7. EMPLOYER CONTACT DETAILS

Name of Employer Business or Organisation

Name of direct Manager/ Supervisor

Address of Organisation

Town / City Postal Code

Province

Phone Number/s

Fax Number/s

* Direct Managers/Supervisors will need to complete section 13 of this application form.

8. COMPUTER LITERACY

How would you rate your computing skills?

Excellent Satisfactory Poor

Do you require additional training in any of the following computer software?If so, please place a tick () in the box

Word Excel PowerPoint No

9. PREVIOUS SCHOLARSHIPS AND EDUCATION

What is your highest level of education?e.g. Grade 10

Have you previously received, or currently hold a scholarship funded by PNG, Australia or another foreign country?

Yes – Please provide details below No – Go to Section 9

Scholarship Name

Qualification

Start Date (mm/yyyy) / / End Date (mm/yyyy) / /

10. ENGLISH LANGUAGE PROFICIENCY

Is English your first language Yes No

If ‘Yes’ go the next section. If ‘No’ answer the following questions:

Was English the language of your highest level of study? Yes No

Have you taken an IELTS or TOEFL test within the last two (2) years? Yes - Please provide details below No – Go to Section 10

Test Name

Test Date Overall Score

Reading Score Writing Score Listening Score Speaking Score

11. MEDICAL / DISABILITY DETAILS

Do you have a serious medical condition currently or historically? Yes No

If yes, please describe the medical condition.

We encourage applications from people who have a disability including those who require additional support to complete their studies

Do you have a disability or special needs? Yes – see below No - go to Section 11

Visual impairment Learning / Intellectual impairment Hearing impairment Physical or mobility impairment

Are there any special requirements which you may need to complete your Fellowship program in Australia? (E.g. wheelchair access, learning aids etc.)

12. PROJECT

All Fellowship participants are required to develop and implement a small project which utilizes the knowledge and skills gained from the course to contribute to their organization and its objectives. The proposed project should be linked to the course topic describe the change in policy, systems, processes or delivery of services within an organizational context. Projects must be achievable in a three to six-month period of time and not require additional funding or resources from the employer organization. Please answer each question in no more than 150 words.

Outline your Project (The change in process, policy, services. The project you aim to complete using the Fellowship)

What is the title of your project?

12. PROJECT

What will the project achieve?

What organisational need, issue or opportunity is the project responding to? (Please attach any report, research or organisational document that identifies the need)

What Organisational objective does the project aligns with? (Organisational Plans) Be specific; include relevant section from organisational plan if possible.

What PNG development priority does the project align with? (from Vision 2050 or other strategic document)

13. SUPPORTING DOCUMENTS

All candidates are required to submit their detailed Curriculum Vitae (CV) and Job Description with this application.

CV attached Yes No

Job Description attached Yes No

14. CURRENT EMPLOYER STATEMENT

This section MUST be completed by the applicant’s current supervisor/ manager.

Please explain your working relationship with the nominated applicant (i.e. you are their immediate supervisor or manager)?

Do you support the nominated applicant participation in the Fellowship?

Yes No

What skills and knowledge do you hope the applicant will gain during the Fellowship that will be beneficial to your organisation?

Briefly explain how the applicant’s proposed ‘project’ will make positive changes to your organisation?

15. APPLICANT DECLARATION AND SIGNATURE

I declare this application is a true and correct record.

15. APPLICANT DECLARATION AND SIGNATURE

Name

Date

Signature

16. CURRENT EMPLOYER’S NOMINATION AND SIGNATURE

This section must be signed by a Senior Representativeof the Organisation.

Official Stamp:

Signed by employer

Name

Position

Phone number

Date signed

This section is for the Australia Awards - PNG Use only

Date received by AustraliaAwards in PNG

Signature of Receiving Officer