APPLICATION FORM TO SELECT PARTICIPANTS FOR THE March 2017

LEADERSHIP ACADEMY FOR DEVELOPMENT (LAD) PROGRAM

The Leadership Academy for Development (LAD), at Stanford University’s Center on Democracy, Development and the Rule of Law (CDDRL), theEconomic Policy Research Center (EPRC) and Ilia State University are opening the application intake for the “The Role of Public Policy in Private Sector Development” workshop which will take place in Tbilisi, Georgia in the first week of March, 2017

APPLICATION NOTES:

APPLICATION DEADLINE: 18.00 Tbilisi Time, Monday, January 16th, 2017

BEFORE COMPLETING THIS FORM, PLEASE READ THE ACCOMPANYING

INFORMATION PACK, WHICH CAN BE DOWNLOADED AT:

PLEASE SUBMIT YOUR COMPLETED FORM IN MICROSOFT WORD (VERSION 2000 OR LATER) OR PDF FORMAT.

PLEASE EMAIL YOUR COMPLETED

APPLICATION FORM ALONG WITH CURRICULUM VITAE/RESUME AND STATEMENT OF PURPOSE TO:

ALL DOCUMENTS MUST BE SUBMITTED IN ENGLISH.

PLEASE NOTE: INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

IF YOU HAVE ANY QUESTIONS WHICH ARE NOT ADDRESSED BY THE ACCOMPANYING

INFORMATION PACK, PLEASE EMAIL:

1. PERSONAL DETAILS
First Name:
Surname/Family Name:
Other Names/Patronymic (in full):
Marital Status: / Sex (F/M):
Date, City and Country of Birth: / Citizenship:
Passport Number, Place of Issue and Date of Expiry:
Current Occupation:
Work Address:
Street:
City:
Region:
Country:
Postal Code: / Home Address:
Street:
City:
Region:
Country:
Postal Code:
Tel. No.:
Email: / Tel. No.:
Mobile Phone No.:
Email:
Skype ID:
Preferred Contact Number:
2. REFEREES
Please provide the contact details of two referees:
Name:
Affiliation:
Work Address:
Email:
Tel. No.:
Relationship to you: / Name:
Affiliation:
Work Address:
Email:
Tel. No.:
Relationship to you:

3. CDDRL AFFILIATION

Are you a fellow of the Draper Hills Summer Fellowship on Democracy and Development?
No Yes

If yes, please provide year of fellowship:

4. DECLARATION OF CONSENT
Please tick all the boxes below to confirm you have:
Attached a copy of your curriculum vitae and statement of purpose
Signed and dated this application form
I hereby declare that the above statements are correct and complete. LAD and EPRC have my permission to process, evaluate and store my personal information. Upon my acceptance to the program, my personal data and photograph may be used in Academy publications and on the LAD or EPRC websites.
Signature: Date:

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