LEADERSHIP DEVELOPMENT PROGRAMME

APPLICATION FORM

There are two sections in this Application Form.
Section I is to be completed by the Employer.
Section II is to be completed by the Nominee.
Please tick (P) the programme and track the nominee is applying for:
r Specialist Track
* Social Worker / Occupational Therapist/ Physiotherapist / Speech Therapist / Psychologist / Counsellor / EIPIC Teacher
r Management Track
*Delete where applicable
INSTRUCTIONS TO EMPLOYER/NOMINEE
1. Nominating agency must be a NCSS member organisation or a MSF-funded organisation.
2. If you wish to make several nominations, please submit one application form per nominee.
3. Applications are open to either Singapore Citizen or Permanent Resident.
4. Nominee must meet the eligibililty critiera for the programmes listed in:
http://www.ssi.sg/ldp
6. Forms that are not fully completed will not be considered.
8. The completed application form (Sections I and II) should be sent to the following address before the closing date to:
The LDP Secretariat
Attn: Ms June Soo
Manager, Social Service Leadership Unit
Human Capital Development Group
298 Tiong Bahru Road
#18-01 Central Plaza
Singapore 168730

Section I: To be completed by the Employer.

1 NOMINEE
Name / Current Designation / Name of Organisation
2 REASONS TO SUPPORT YOUR NOMINATION
·  Please state the contributions that the nominee has made to your organisation and/or community. You may also share any significant changes or improvements which the nominee has made to your organisation that resulted in impact beyond his / her immediate level of responsibilities.
3 POTENTIAL
3.1 Potential
(Please indicate an estimation of the highest appointment or level of work the nominee can potentially handle ultimately.)
Management Track
r Executive Director
r Centre Head /Assistant Director*
r Manager/Senior Manager*
r Others (please specify) : / Specialist Track
r Master * Social Worker / Therapist / Counsellor / Psychologist / EIPIC Teacher
r Head of Professional Services*/Principal Social Worker/ Therapist / Counsellor / Psychologist / EIPIC Teacher
r Others (please specify):
3.2 Please provide a copy of the job description at the highest appointment or level of work the nominee can potentially handle ultimately.
3.3 Career Progression Plan for Nominee to Assume the Position as indicated in question 3.1.
Years of Experience
(pls indicate) / Specialist Track
Social Worker / Therapist / Counsellor / Psychologist / EIPIC Teacher / Managment Track
Master / Executive Director/Director
(large agency)
Head of Professional Services / Centre Head
Principal / Assistant Director
Senior / Manager/Senior Manager
3.4 (a) How many direct reports is the nominee currently managing? ______
(b) Please indicate how many level (s) in the organisational structure, the nominee will need
to advance to the appointment indicated in 3.1 from his/her current position?
______
Please enclose a copy of the organisation chart mapping out the nominee’s route of advancement from the current position to the highest appointment.
*delete where applicable
4 OVERALL PERFORMANCE OF NOMINEE
Please enclose 3 years of performance appraisals for the nominee.
5. LEARNING AND DEVELOPMENT
5.1 What are the relevant training you would recommend the nominee to enrol in the next 2 years to support nominee’s:
(a) potential to assume the highest position and career progression plan as described in Question 3.3;
(b) learning need(s) identified during performance appraisal; and
(c) general courses (e.g. short courses for management training), professional development programmes (e.g. short courses/conferences/postgraduate programmes for professional skills training) and Management programmes (e.g. Leadership programmes/postgraduate programmes), etc.
Please complete the table below and provide course outlines. The Individual Development Plan will be reviewed once in 2 years.
(Please refer to http://www.ssi.sg/ldp for the funding quantum of different training and development categories under the Leadership Development Grant.)
Learning & Development / Description of Action Plan / Course Fee
Title of Course / Institution/
Training Provider
r  Short Courses/ Overseas Conference -Professional Skills Training
(Courses that enhance the professional skills and not leading to formal qualifications) / __ / __
__ / __
__ / __
r  Short Courses / Overseas Conference -Management Skills Training
(Courses that enhance the management or leadership skills and not leading to formal qualifications) / __ / __
__ / __
__ / __
r  Leadership Programmes
(Advanced leadership and management skills programmes to help candidate achieve his/her leadership potential.) / _ / __
__ / __
__ / __
Learning & Development / Description of Action Plan / Course Fee
Title of Course / Institution/
Training Provider
r  Work Attachment Programme
(Attachment to appropriate organisations- local/overseas) / __ / __
__ / __
__ / __
r  Postgraduate Programmes
(Courses that lead to formal certification/ qualifications) / __ / __
__ / __
__ / __
6.2 Please describe why the above learning and development plan is proposed (e.g. the benefits of the proposed learning and development programmes to the organisation and nominee.)

*CNPL – Centre for Non-Profit Leadership

7 NOMINATING ORGANISATION
Name of Organisation: ______
Email Address: ______
Contact Number: ______
Nominated by:
______
Name of Executive Director/Centre Head Signature Date
Supported By:
______
Name of Chairman Signature Date
Organisation Stamp:


Section II: To be completed by Nominee

PERSONAL PARTICULARS

Name (As in NRIC/ Passport, please underline surname)
*(Dr/ Mr/ Mdm/ Miss) / Aliases (If Any) / Please paste your photograph here.
Address / *NRIC No./Passport No.
Residence Status
*Singaporean/PR
Contact No
Home: / Office
/
Mobile
/
Email Address
Date of Birth
/ Age
/
Gender
*Male / Female
/
Race/Dialect
/
Nationality
Accreditation Status:
r *Registered Social Worker / Therapist / Psychologist / Counsellor / Not applicable
EDUCATIONAL QUALIFICATIONS (Please attach copies of all educational certificates, transcripts, testimonials, etc.)
Name of School/Institution/Country / Course of Study / Period / Highest Qualification Obtained
(Please indicate your Honours classification and overall CAP/GPA score if applicable.)
From
(MM/YY) / To
(MM/YY)
SCHOLARSHIP/ TRAINING AWARDS
Date of Award / Name of Scholarship/ Training / Name of Organisation which awarded the scholarship / Course of Study / Period of Bond
(MM/YY)

* Delete where applicable

PROFESSIONAL MEMBERSHIPS
From
(MM/YY) / To
(MM/YY) / Association/Society/Company / Position Held
EMPLOYMENT HISTORY (Please give details of your employment history including non-social service sector beginning with the most recent employer. If space is insufficient, please provide the information on a separate sheet of paper.)
From (MM/YY) / To (MM/YY) / Name of Organisation / Last Position Held / Job Roles and Responsibilities
CAREER ASPIRATIONS
What are your career goals in the next 5 years? How would you like the programme to support you in meeting your career aspirations?
(Please limit to no more than 300 words.)
REFLECTION OF OVERCOMING SETBACK (ONLY applicable for LDP)
Share a past instance where you had encountered a setback in your professional domain and how you dealt with the situation.
(Please limit to no more than 300 words.)
CHARACTER REFEREES (ONLY applicable for LDP)
(Please provide particulars of two persons who are not related to you, preferably past employers or current employer. They should know you well with regard to your character and work performance.)
Referee 1
Name / Organisation / Designation
Mailing Address / Contact Number
Email Address / Years Known
Referee 2
Name / Organisation / Designation
Mailing Address / Contact Number
Email Address / Years Known
OTHER INFORMATION
1. Are you serving any bond with your present employer ? / Yes / No*
2. Do you have a criminal record in Singapore? This refers to a criminal record under the Registration of Criminal Acts.
If yes, please specify ______/ Yes / No*
3. Have you ever been convicted in a court of law in any other country (excluding parking offences or criminal records disclosed above)?
If yes, please specify ______/ Yes / No*
DECLARATION
I give my consent to the National Council of Social Service to obtain and verify from or with any source, as you deem appropriate for the assessment of my application for the Leadership Development Programme.
I declare that the particulars stated in this application and the attached documents are true to the best of my knowledge and belief, and that I have not wilfully suppressed or falsified any information.
______
Date Signature

* Delete where applicable

FOR OFFICIAL USE ONLY
Shortlisted for interview:
□ Selected / □ KIV / □ Rejected
Processed by:
Date:

1

LDPV6-Sep16 CONFIDENTIAL