Application for Admission 2012
Application closing date:
Central agencies are required to send applications to ANZSOG by 9 September 2011
Jurisdiction
Commonwealth Northern Territory Victoria
New Zealand Queensland Western Australia
Australian Capital Territory South Australia
New South Wales Tasmania
Personal Details (please type or print clearly)
Title / Dr Mr Ms
Other / Given name
Surname / Preferred given name
Postal address (to which correspondence and reading materials will be sent)
Telephone work / Telephone home
Facsimile / Mobile
Date of birth / Gender / Male Female
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.
Personal Details (cont’d)
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 a disability?* / Yes (go to next question)
No
I choose not to give this information
What is the nature of your disability? / ______
I choose not to give this information
* For the purpose of this collection, a disability is any physical, intellectual or psychological restriction or lack of ability (arising from an impairment) to perform an activity in the manner or within the range considered normal. Impairment can include people suffering from ongoing illness or injury. Examples of a few specific disabilities include asthma, epilepsy, arthritis, depression, loss of sight (not correctable by glasses or contact lenses), loss of hearing, incomplete use of any part of the body, head injury or speech difficulties. These are only a few specific disabilities, there are many more.
Dietary and other 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
Department/Agency/Other
Division
Job Title
Date commencement / Current public service level
Number of years at this level / Number of years of public sector employment
Employment History
Employer:
Job Title:
Responsibilities: / From:
To:
Employer:
Job Title:
Responsibilities: / From:
To:
Employer:
Job Title:
Responsibilities: / From:
To:
Employer:
Job Title:
Responsibilities: / From:
To:
Academic History
Please list all degrees or diplomas awarded. It is essential that youattach certified copies of academic results.A certified copy is a photocopy of the original document with the signature and official stamp of an appropriate authority, confirming it is a true and accurate record.
Name of Degree/Diploma / Institution / Start Year / End Year
University choice
This degree is awarded by any one of our participating universities. Please note admission to a university is a separate procedure from this application and that universities have differing entry requirements. Please nominate your selected university and we will provide details of how to enrol.
Australian National University
Charles Darwin University
Curtin University of Technology
Flinders University
Griffith University
Monash University
University of Canberra
University of Melbourne
University of Sydney/University of New South Wales/ (you will have joint enrolment at both Universities)
University of Western Australia
Victoria University of Wellington
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 the degree?
What are your long term objectives, and how will the degree help you achieve them?
Outline your learning and development needs.
Manager details
This is the person to whom you report or the person responsible for managing or supporting you in this program.
Name
Title
Division
Department/Agency/Other
Postal address
Telephone / Facsimile
Please describe the workplace support you and your agency will provide for the candidate
Invoicing details
This is the person ANZSOG is to invoice for the fees of this program. These details are not required for applicants from QLD where invoices are facilitated through the central agency.
Name
Title
Division
Department/Agency/Other
Postal address
Telephone / Facsimile
The EMPA Mentor Program
Each student sponsored in the EMPA program is required to have a mentor nominated by their agency with whom they can form an encouraging and constructive relationship during their time on the program. It is assumed that the mentor will be a manager from the sponsoring agency’s senior leadership group who does not have a direct reporting relationship with the student.ANZSOG provides guidance and support to both students and their mentors at the commencement of the program.
Further details about mentoring and the EMPA mentor program can be found at
Mentor details
This is the person in your department/agency who will act as your mentor for the duration of the program.
Name
Title
Division
Department/Agency/Other
Postal address
Telephone / Facsimile
Referee details
Please provide the name and contact details of the person you have asked to be your referee. We 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 (page 11 and 12).
Name
Title
Division
Department/Agency/Other
Postal address
Telephone / Facsimile
Application declaration
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.
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.
Declaration
I declare that to the best of my knowledge the information on this form is correct and complete. I acknowledge that
the provision of incorrect information or the withholding of any information relating to my academic or employmentrecord or permanent residency status may result in the withdrawal by the institution of a place and that this withdrawalmay take place at any stage during the tertiary course I undertake. I recognise that this application is submitted and received on the understanding that 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 that 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
Applicant signature / Date
How did you hear about this program? (you may tick more than one box)
Internet Learning and Development Dept Other (please specify)
Colleague ANZSOG information session
Manager Other ANZSOG program
Checklist
Your application must be complete to be processed. When your application is complete, please ensure you have:
Completed the entire application form
Signed the form on the last page
Attached certified copies of academic transcripts
Attached a certified copy of proof of permanent residency if citizenship not Australian or New Zealand
Provided the name and contact details of your manager
Provided the name and contact details of the person to whom an invoice will be sent
Provided the name and contact details of your referee
Obtained and included a completed Referee Report
Provided the name and contact details of your mentor while you are on the program
What happens next?
- Send your application to the Coordinator in your department/ agency.
- Applications for available places will be forwarded to the Selection Committee at ANZSOG.
- You will be notified of ANZSOG’s decision.
- After ANZSOG selection we will contact you regarding enrolment at your nominated university.
Enquiries
Information about ANZSOG and the EMPA can be found on our website atIf you have any further queries about your application please contact, Linda Losanno, StudentCoordinator, on:
Phone:+61 3 8344 1969
Fax:+61 3 9349 5849
Email:
Degree of Executive Master of Public Administration
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
Title
Division
Department/Agency/Other
Postal address
Telephone / Facsimile
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.
Signature / Date
Thank you for completing this report. Please return it to the applicant for inclusion with the application form.
ANZSOG EMPA 2012 Application Form 1