Public Sector Commission

2017 EMPA Scholarship Application form

Executive Master of Public Administration (EMPA)

2017Western Australian application for admission

Applications close Friday 29July2016

Please note: You must prepare and submit three copies of your application to the Public Sector Commission.

Jurisdiction

Western Australia

Personal details(please type or print clearly)

Title: / Dr
Mr
Ms / Miss
Other / Gender: / Male
Female
Given name:
Preferred name:
Surname:
Date of birth:
Telephone (w):
Telephone (h):
Mobile:
Work email:
Secondary email:
Postal address:
(to which correspondence and reading materials will be sent) / Suburb: / Postcode:
Country of Citizenship:
Are you a permanent resident of Australia?* / Yes / No
Are you a permanent resident of New Zealand?* / Yes / No
*Please include a certified copy of your permanent resident status as this is required by the universities.
Do you identify as Aboriginal, Torres Strait Islander, Maori or Pacific Peoples? / Yes / No
I choose not to give this information
In what country were you born?
I choose not to give this information
Do you have a non-English speaking background? / Yes / No
I choose not to give this information
Do you have accessibility requirements and/or need other adjustments in order to participate in this program? / Yes / No
I choose not to give this information
If yes, please specify
I choose not to give this information
Dietary requirements allergies or other special requirements:
As some subjects are taught as residential programs please advise if you have any requirements that we should be aware of.

Current employment details

Agency:
Division:
Position title:
Commencement date:
Current level: / Number of years at this level:
Numbers of years of public sector employment:
Job function:
(please indicate which function/s your current job involves) / Corporate services (HR, financial management, IT, legal)
Ministerial adviser
Policy design/development
Technical advice (e.g. medical, agricultural)
Service delivery/policy implementation/operations management
Staff management
Strategy
Other

Employment history

Employer:
From: / To:
Job Title:
Responsibilities:
Employer:
From: / To:
Job Title:
Responsibilities:
Employer:
From: / To:
Job Title:
Responsibilities:
Employer:
From: / To:
Job Title:
Responsibilities:

Academic history

Please list all degrees or diplomas awarded. You must attach certified copies of academic results. Please refer to the Scholarship guidelines for further details.

Degree/Diploma / Start year
Institution / End year
Degree/Diploma / Start year
Institution / End year
Degree/Diploma / Start year
Institution / End year
Degree/Diploma / Start year
Institution / End year

University choice

This degree is awarded by any one of ANZSOG’s participating universities. Please note admission to a university is a separate procedure from this application and that universities have differing entry requirements.The nominated university for the 2017 intake is Curtin University of Technology,ANZSOG will provide details of how to enrol.

Curtin University of Technology

Personal statement

This personal statement is designed to help the Selection Committee learn more about you and your motivations for undertaking the degree and your desired learning outcomes.

What are your reasons for undertaking this degree?
What are your long term objectives, and how will the degree help you achieve them?
Outline your learning and development needs.
Briefly discuss your career goal(s) for the next three to five years.
Explain how completing this degree will add value to your agency?
How will you share your learning with others?
How will you manage a significant study load in addition to your current work and personal commitments?
If successful for a scholarship how will you give back to the public sector, or pay it forward?
Is there anything you would like to add in support of your application?

Manager details

This is the person to whom you report, or the person responsible for managing or supporting you in this program.

Title: / Dr
Mr
Ms / Miss
Other / Gender: / Male
Female
Given name:
Surname:
Job title:
Division:
Agency:
Telephone (w):
Work email:
Postal address:
Suburb: / Postcode:
Please describe the workplace support you and your agency will provide for the candidate.

The EMPA mentor program

The EMPA mentoring program is a formalised and monitored program that will enhance the leadership journey for EMPA students. Each student will nominate a mentor from their agency with whom they can form an encouraging and constructive relationship.

Ideally the mentor will be a manager from the agency’s senior leadership group who does not have a direct reporting relationship with the student (mentee). The mentor and mentee will establish a mutual commitment of expectations and objectives in their mentoring relationship and ANZSOG encourages them to formalise this in a written agreement. It is expected that each party will participate in the ANZSOG mentor review process during the program.

The EMPA mentoring program extends over the two years of study. However the relationship and critical discourse between mentor and mentee will become active during the last eighteen months of this period i.e. from July of the first year in the EMPA program until December of the final year.

To support participation in the program, ANZSOG will provide resources for mentors and mentees at the start of the EMPA year.

Further details about mentoring and the EMPA mentor program can be found at

Mentor details

This is the person in your agency who will act as your mentor for the duration of the program.

Title: / Dr
Mr
Ms / Miss
Other / Gender: / Male
Female
Given name:
Surname:
Job title:
Division:
Agency:
Telephone (w):
Work email:
Postal address:
Suburb: / Postcode:

HR/Learning & Development Co-ordinator

This is the person in your agency who has co-ordinated an internal selection process and nominated eligible applicants.

Given name:
Surname:
Job title:
Division:
Agency:
Telephone (w):
Work email:

Referee details

ANZSOG may contact this person about your application. We suggest that your referee is someone who is familiar with your work and your ability to perform in this program.

Please note: your referee must complete the ‘Referee Report’ at the back of this application form (pages 15 and 16).

Given name:
Surname:
Job title:
Division:
Agency:
Telephone (w):
Work email:
Postal address:
Suburb: / Postcode:

Invoicing details

Scholarships offered by the Public Sector Commission cover the ANZSOG tuition fee andexpenses incurred whilst attending workshops. This includes travel, accommodation and meals.

Please refer to the Scholarship guidelines for further information on reimbursement and financial administration.

How did you hear about this program?(you may tick more than one box)

colleague
manager
alumni
advertisement / direct mail
direct email
other ANZSOG program
ANZSOG event
ANZSOG website / Learning & Development unit
Other website (please specify):
______
Other (please specify):
______

Application declaration

ANZSOG Privacy Statement

As part of the services provided by ANZSOG, it collects and records personal information about applicants from a number of sources. In dealing with personal information, ANZSOG complies with the National Privacy Principles as set out in the Privacy Act 1988 (Commonwealth) and the Privacy Amendment (Private Sector) Act 2000 (Commonwealth). In particular, ANZSOG may disclose personal information collected about applicants to participating universities and to the applicant’s sponsor. Further details about the ANZSOG privacy policy may be found at the ANZSOG website.

ANZSOG Disclaimer

Information provided about courses and curriculum and any arrangements, including staffing, are an expression of intent only and are not to be taken as a firm offer or undertaking. ANZSOG reserves the right to discontinue or vary such courses and curriculum or arrangements at any time without notice and to impose limitations on enrolment in any course or subject.

Successful applicants to ANZSOG’s EMPA are required to enrol in a participating university to gain entry into the degree. Applicants must also satisfy the eligibility and enrolment requirements of their chosen participating university. ANZSOG therefore cannot guarantee enrolment into the course at any participating university.

Applicant declaration

I declare to the best of my knowledge the information on this form is correct and complete.

I acknowledge provision of incorrect information or withholding any information relating to my academic or employment record or permanent residency status may result in the withdrawal by the institution of a place and that this withdrawal may take place at any stage during the tertiary course I undertake. I recognise this application is submitted and received on the understanding the institution may obtain official records with respect to my application from the appropriate education institution(s).

In signing this application I acknowledge I have read, and agree that I will comply with:

  • the ANZSOG Privacy Policy at

I give permission for my contact details in this application to be given to the teaching faculty and other students on the course

  • the ANZSOG Intellectual Property Policy at

I understand the ANZSOG Intellectual Property Policy contains important information about ownership of intellectual property rights in material that I create as an ANZSOG student, and about my rights to use that material

  • the ANZSOG Student Code of Conduct at

Public Sector Commission Scholarship applicant declaration

Information provided as part of this application will be used by the selection panel to rank applications as per the program criteria.

I acknowledge that I have read and understood the Public Sector Commission’s Scholarship guidelines.If successful in my application,I confirm that I agree to:

attend all required workshops

undertake all required coursework to the best of my ability

abide by the aforementioned ANZSOG policies and codes pertaining to the program

abide by the scholarship guidelines set by the Public Sector Commission

notify the Public Sector Commission of any changes to my circumstances which may affect my eligibility or ability to complete the program

actively participate in program evaluation and provide feedback to the Public Sector Commission

participate in post-program whole-of-government projects and initiatives.

Applicant signature:
Date:

Applicant checklist

Your application must be complete to be processed. The Commission does not accept and will return any incomplete applications.

Please ensure you have:

completed the entire application form and answered all questions

signed the ANZSOG Applicant declaration andthe Public Sector Commission’s scholarship applicant declaration

attached certified copies of academic transcripts

attached a copy of your current resume, addressing sections 3.2 and 3.3 of the Scholarship guidelines

attached a certified copy of your proof of permanent residency if you do not hold an Australian or
New Zealand citizenship

provided the name and contact details of your manager

provided the name and contact details of your referee

obtained and included a completed referee report

completed the CEO endorsement form

prepared three copies of your application for submission.

What happens next?

  1. Send your three copies of your application to:

Carol Williams

Public Sector Renewal

Public Sector Commission

Locked Bag 3002

WEST PERTH WA 6872

Applications close COB Friday 29July 2016

  1. The Public Sector Commission will rank applicants against the scholarship selection criteria and forward the recommended applicants to the ANZSOG Selection Committee for consideration.
  2. You will be notified of ANZSOG’s decision.
  3. If successful, ANZSOG will contact you regarding enrolment at your nominated university and the Public Sector Commission will invite you to a Welcome Session for participants.

Enquiries

Queries regarding the scholarship and application process should be directed to the Public Sector Leadership team at on (08) 6552 8894.

Information about ANZSOG and the EMPA can be found on the ANZSOG website at Further queries about the program can be directed to Tim Wigg, EMPA Co-ordinator, at or on (03) 9035 3279.

Executive Master of Public Administration (EMPA)

Western Australian application for admission 2017

Referee report

You have been nominated as a referee for an applicant for admission to the degree of Executive Master of Public Administration. Please complete this form in support of his/her application and return it to the applicant for submission with the application.

Applicant’s name:
Referee name:
Job title:
Division:
Agency/Company:
Telephone (w):
Work email:
Postal address:
Suburb: / Postcode:
How long have you known the applicant and in what capacity?
What do you believe are the applicant’s learning and development needs?
How do you see the degree contributing to the applicant’s professional progression?
Please comment on the suitability of the applicant for this program.
Referee’s signature:
Date:

Thank you for completing this report. Please return it to the applicant for inclusion with the application form.

Executive Master of Public Administration (EMPA)

Western Australian application for admission 2017

Agency Chief Executive Officer endorsement

Title: / Dr
Mr
Ms / Miss
Other / Gender: / Male
Female
First name:
Surname:
Job title:

As Chief Executive Officer, I agree to the applicant being released to attend all aspects of the ANZSOG Executive Master of Public Administration (EMPA), including preparation and evaluation sessions with the Public Sector Commission.

I acknowledge the agency will be reimbursed for study related expenses, including travel and meals, once an expense claim form and supporting documents have been provided to the Public Sector Commission. I understand the agency may be liable for expenses if reimbursement documents are not submitted to the Commission by the nominated date.

I support the applicant in their studies of the EMPPA and upon graduation I will support their future participation in whole-of-government initiatives, which may include future Senior Executive Service mobility initiatives.

CEO signature:
Date:

If you are endorsing more than one applicant for this program, please indicate the order of preference:

Applicant Name
First
Second
Third

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