Lean Six Sigma Green Belt programme application form – MLA01

UCD Course Code - Lean 6 Sigma Green Belt (NMHS32280)

To be completed by the APPLICANT[right click on the tick box, click ‘properties’ and select ‘checked’ under the Default Value]
Surname / Click here to enter name
First Name / Click here to enter name
Mother’s Surname at Birth / Click here to enter name / Country of Birth:
Date of Birth / Click here to enter date / Male Female / Nationality:
Have you studied at UCD before? / No Yes / UCD Student number
Have you applied for Green Belt before? / No Yes / Date of application
Hospital/Organisation name / Click here to enter hospital / Staff number
Directorate and Department / Click here to enter directorate and department
Title and Grade / Click here to enter your title and grade
Contact Phone No / Click here to enter number
Email Address (BLOCK CAPITALS) / Click here to enter email
Project idea identified Yes Candidates must have considered a project as part of their application process.
Successful applicants will be notified by the 3rd April 2015. At this stage the successful candidates will be issued with a project charter to complete (project charters must then be submitted by the 17th April 2015). The Mater Lean Academy Steering Group will decide on the projects to be pursued and candidates may expect to be assigned to any project group.
In accordance with the Mater Lean Six Sigma Academy protocol I confirm that I have liaised with my line manager for release to attend Lean Six Sigma Green Belt training on the dates stipulated below, and that my manager has signed this form accordingly.
Programme dates 2015:
Full day (9.00- 16.00)
6thMay 2015
Half days (9.00 -13.00)
3rd June 201510th June 201524th June 20158th July 201522nd July 201519thAug 2015
16thSep 201530thSep 20151 full day for final project preparation and presentation
Candidates must attend the full day and minimum attendance at half day programmes is 90%.
To be completed by the LINE MANAGER
I confirm that the applicant has met with me and informed me of the time and commitment required to complete the Lean Six Sigma Green Belt programme with the Mater Lean Academy.
Signature
Name / Click here to enter name
Grade / Click here to enter grade.
Department / Click here to enter department
Contact Phone No / Click here to enter number
Email Address / Click here to enter email address.