On-the-Job Analytical Skills for Member-Owned Microfinance Practitioners
Online Course Application Form

Regular Application Deadline February 2, 2018

First Name / Family Name
Date of Birth MM/DD/YY
Gender
Name of Course / On-the-Job Analytical Skills for Member-Owned Microfinance Practitioners
Date of Course / January 29 – April 27, 2018

Your Personal Contact Information

Street Address
City
Province/State
Country / Postal Code
*Primary Phone # / *Secondary Phone #
Cell or Landline / Cell or Landline
Primary Email / Fax
Secondary Email / Skype Address

*Please include your, country code, area code and full phone number. Sometimes there is a difference for cell phones. See this link for reference: If your country is not listed, then get in touch with your cellphone provider.

Your Work Experience

Job Title
Level of Responsibility Within Your Organization
Senior Management (example, managing a region or organization)
Middle Management (example: field coordinator, project manager)
Entry Level (example: extension worker, assistant, intern, other)
Your current role and responsibilities:
Organization Name
Website of Organization
Organization Street
Organization City
Country / Postal Code
Telephone / Mobile Phone
Email / Fax
Type of Organization. Please choose one.
International NGO / National NGO / Local Association or cooperative
Local NGO / Government Body / Donor
Consultant / Private Sector / Academic / Research / Network
Other (please explain):
How many years of relevant work experience do you have related to savings groups or member-owned microfinance?

Your Education

Secondary School / Certificate / Diploma
BA/BSc / Masters / PhD
Other trainingand Professional Development regarding microfinance, savings groups or relevant content
Dates Attended / Name of Course / Institute/Training Provider
How will your participation in this course affect greater change in your organizational outcomes? Please be specific.

Access to Internet and Online Experience

As this is an online course, we would like to adapt our delivery of the course to

your internet accessibility.

What type of Internet access do you have?
High Speed Reliable / High Speed Intermittent
Low Speed Reliable / Low Speed Intermittent
Dial Up Reliable / Dial Up Intermittent
Please number all of the following devices that you will use for this course marking 1 as your primary device:
Personal Tablet / Personal Work Tablet
Personal Computer / Work Computer
Shared Family Computer / Work Shared Work Computer
Cell Phone / Other
What is your experience with online learning?
I have done searches online but never a discussion, webinar or course / I have taken an online course before
I have participated in at least one webinar / I have facilitated an online discussion or webinar
I have participated in at least one online discussions or listserve discussion / I have facilitated an online course

Please tell us how you found out about the SMDP Online at the Carsey School of Public Policy and its programs. Check all that apply.

From a staff person in your organization
From a SMDP Alumni / Name of Alumni
Saw an advertisement / Where did you see this ad?
In an e-mail from the Carsey School of Public Policy
MaFi
BEAM Exchange, LinkedIn
SEEP Mango Tree
On the internet / Please specify
Microfinance Gateway
Other / Please specify
Have you attended any other SMDP programs? Yes No
If yes, did you receive a SMDP MasterCard foundation scholarship? Yes No
If yes, how has your work/position changed since then?

Tuition Payment Information

Full tuition for this course is USD $1,600.00

Please describe how you will make payment for tuition – Check correct box
Wire Transfer / Credit Card / Check from U.S. Bank
PAYMENT INSTRUCTIONS
Students will make payments directly to the Carsey School of Public Policy/University of New Hampshire in U.S. dollars and can pay by check from a U.S. bank, credit card, or wire transfer. Credit card payments are subject to a 2 percent processing fee on the total transaction amount. Please note that if payment is made by wire transfer, you must add $35 for the wire transfer fee.
A deposit of $500.00 is due within 10 days of registration. The balance of tuition must be paid by the first day of the courseJanuary 29, 2018
Check
Please make payable to:
University of New Hampshire/SMDP and mail with a copy of this registration to:
Carsey School of Public Policy/SMDP New Hampshire
University of New Hampshire
73 Main Street, Huddleston Hall
Durham, NH USA 03824
Wire Transfer
Please contact the SMDP Registration Manager for wire transfer instructions
Be sure to include your name on the draft and send us an email or fax letting us know that it has been processed. Please add a $35 fee to cover the cost of the transfer and other bank charges. Note, there is no standard rate for such costs and therefore it may vary from the recommended $35. In such a case, if your payments are either short or greater than the amount you owe, we will settle it while you are at the school. The payment amount will be based on the notification we receive from our bank as to what the actual deposit is, therefore make sure you correspond with us at regarding this.
Credit Card
If you wish to pay by credit card, please contact the SMDP office at or call 01-603-862-3603 and we can take your card information over the phone.
We will initially charge a $500 plus 2% processing fee ($10) for a total deposit of $510 to your card for each person you register upon receipt of your registration(s). The remaining balance will be charged against your card before you begin the course.
Once your deposit or full payment has been received, we will send you an email confirmation.
For payment questions, contact or call
01-603-862-3603 (Fax 01-603-862-3878).
MasterCard Foundation Scholar Applications
If you complete the MasterCard Foundation Scholarship section below and commit to paying a share of the tuition for your course, you will be required to make this payment as soon as you have been accepted to the program. If you do not make the payment within two weeks of notification of your award, you may forfeit your scholarship opportunity.
Refund Information:
If you cannot attend the SMDP Online course, you may request a refund in writing or via email. Requests received before February 15, 2018, will be refunded in full, less a $100 processing fee. There will be no refunds for cancellations received after that date. It can take up to 4 weeks once you request a refund for payment to be processed. The refund will be remitted in the form it was received. For example, credit card payments will be issued a credit back to the original card the charge was made on (due to credit card regulations we are unable to make exceptions to this policy), and wire transfers will be refunded via wire.

The MasterCard Foundation Scholarship Application
SMDP Online
Winter-Spring 2018

Deadline for Application Submission January 16, 2018

Please read the eligibility information below carefully and do not apply for a scholarship if you do not meet most of the stated criteria. Your entire application will be rejected if you do not meet most of the listed criteria. Please check all that apply.

Recommendation Criteria:

Scholarship recommendations will be determined by the following criteria:

oHow well does the applicant meet the eligibility selection preferences listed?

oBased on the candidate’s stated background profile, how would the scholarship make an impact on her professional development and to the organization?

Note: Click on the box to select it and type your response

Scholarship Eligibility Criteria and Statement
I am applying for scholarship support from the MasterCard Foundation Microfinance Scholars Program scholarship program and I certify that the following information is true.
I have not previously received a scholarship from the MasterCard Foundation
I am a practitioner with at least two years’ experience in the course topic
I am a woman or work with an organization that primarily serves women and youth / I primarily work in Africa
I work foran NGO, development finance institution, policy development organization, or private firm.
My background can be described a disadvantaged from rural and/or a resource-poor area
I can make a contribution of at least 10% of the tuition fee or $160.00
Please state amount of contribution
I agree to make the contribution amount stated above by the program deadline if my scholarship application is approved.

Admissions Office
Please email the complete application to SMDP Online

Carsey School of Public Policy

1

On-the-Job Analytical Skills for Member-Owned Microfinance Practitioners
An Online Course for Savings Groups Professionals
Online Course Application Form