FOR OFFICIAL USE Received application by administration: Local Political Leaders – Capacitating Women in Politics
Sign______________________
Inception workshop in spring 2016 Training in Sweden in October 2016
Comment, see attached note
Date___________________
APPLICATION FORM (Typewriting or block letters) Nominated_____________________________________________________________________________________________ (name of applicant) Country_______________________________________________________________________________________________ The__________________________________________________________________________________________________ (name of nominating municipality/region) To the programme ”Local Political Leaders”
(When necessary/applicable) The Nomination is approved by (name of authorizing authority)____________________________________________________ in accordance with local rules. Date______________________
The Application should be submitted to the ICLD no later than January 31st, 2016. Applications received after this date will not be considered. Documents sent my e-mail should be addressed: info@icld.se and referring to ITP – Application in the header Documents sent by courier service should be addressed: ITP - Application Swedish International Centre for Local Democracy Hamnplan 1 SE-621 57 Visby, Sweden
PERSONAL HISTORY 1. Names as written in passport (underline name by which formally addressed)
2. Office address
3. Telephone (office) (country code/area code)
E-mail (obligatory) 4. Home address
5. Telephone (home) (country code/area code) Mobile phone
E-mail (home) 6. Nationality
Date of birth Day
7. Airport of departure for international travel
Passport number
Month
Year
Enclosed copy of passport 8. Sex
Male
Female
Other
9. Have you participated in any ITP (International Training Programme) in Sweden before? Yes
No
Name of programme, year_____________________________________________________________
POLITICAL RECORD Do you hold an elected position? Yes
Type of organization
No
Local Government National Government
Are you Mayor
Vice Mayor
Councilor
Are you a member of a Committee
municipal/regional board
If yes, which: _____________________________________ State the name of your party: ________________________________________________ Is your party currently in Majority
Regional Government
Opposition
How many years (in total) have you had an elected seat? _____________
Description of your work, including your personal responsibilities
Other__________________________________________
Computer knowledge (rate from 0 to 5, where 0 = no knowledge, 3 = normal user, 5 = expert) Applications Word_____ Power Point_____ Excel_________
I have access to internet No
Yes
If yes
at work
at home
elsewhere
Strategic issue Enclosed description 1-2 pages including: 1) Background and explanation of the role and responsibility of the applicant. 2) Problem analysis and/or situation analysis. 3) Strategic issue identified, and which tools needed to grow as a leader.
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ENGLISH LANGUAGE SKILLS ABILITY TO UNDERSTAND Understands without difficulty when addressed at normal rate
Understands almost everything, if addressed slowly and carefully Requires frequent repetition and/or translation of words and phrases
ABILITY TO SPEAK Speaks fluently and accurately and is easily intelligible
Speaks intelligibly, but is not fluent or altogether accurate Speaks haltingly, and is often at a loss for words and phrases
ABILITY TO WRITE
READING ABILITY AND COMPREHENSION
Writes with ease and accuracy Writes slowly and with only a moderate degree of accuracy Writes with difficulty and makes frequent mistakes
Reads fluently, with full comprehension Reads slowly, but understands almost everything Reads with difficulty, and only with frequent recourse to a dictionary
MEDICAL STATEMENT
I do not have any infectious diseases (for example tuberculosis or trachoma) or any other illnesses which could present risks to persons that I will come in contact with.
I do not have any medical conditions which prevent me from carrying out training away from home. I am in good health and enjoying full working capacity.
Comment:____________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Information to all applicants according to the Swedish Personal Data Act: Upon confirmation that your application has been accepted, the personal information that you have given in this application will be used by the Programme Organizer in administering the programme. Your personal data will also be available to ICLD for internal use. The data will not be used for other purposes.
I certify that my statement in answer to the foregoing questions is true, complete and correct to the best of my knowledge and belief. If selected as a participant I undertake to spend the time during the period of the programme as directed by the programme management. Date____________________________________ If you are selected, you vill be notified by e-mail. Please confirm your acceptance to attend by e-mail.
For information or questions regarding the programme, please contact: Kristin Ekström Programme Manager E-mail: kristin.ekstrom@icld.se