Moremi Initiative for Women’s Leadership in Africa
Engaging, Equipping and Inspiring the Next Generation of African Women Leaders
Confidential Application – Class of 2010

GENERAL INFORMATION

Please type or print in ink.

PARTICIPANT NAME

Surname

First/Given

DATE OF BIRTH:

Other information

SCHOOL/ ORGANIZATION :

LEVEL/ JOB TITLE:

MAILING ADDRESS:

City

Province/State

Country

Postal code

PHONE:

- -

FAX:

E-MAIL ADDRESS:

OTHER PHONE:

- -

FAX:

ADDITIONAL E-MAIL ADDRESS:

COUNTRY OF ORIGIN:

How did you hear about Moremi Initiative?

Have you participated in any other Leadership programs? If so, list programs

EDUCATIONAL BACKGROUND

NAME AND LOCATION OF INSTITUTION

FIELD OF STUDY

DEGREE/ CERTIFICATE

YEAR

COMMUNITY SERVICE*Include community, civic, religious, political, or government activities. Please do not include business or professional activities.

MOST SIGNIFICANT COMMUNITY ACTIVITY	ORGANIZATION	ASSIGNMENT	YEAR	RESPONSIBILITY

COMMUNITY OR CIVIC AWARDS AND HONORS

AWARD OR HONORS	ORGANIZATION	DATE

FIELDS OF WORK AND AREAS OF INTEREST

Health and Safety

HIV/AIDS

Reproductive Health

Maternal and Child Health

Education

Education

Formal / Non-formal Education

Vocational training

Democracy & Governance

Civil Society Strengthening

Conflict Mitigation & Management

Women’s Political Participation

Economic Empowerment

Poverty Reduction / Income Generation

Micro-finance / Micro-credit

Small / Medium Business Development

Gender Equity and Women’s Rights

Violence Against Women

Human Rights / Women’s Rights

Other areas- please list:

EMPLOYMENT

EMPLOYER	RESPONSIBILITY	START DATE	END DATE	TITLE

PROFESSIONAL or COMMUNITY AFFILIATIONS

ORGANIZATION	POSITION HELD	DATE

APPLICANT ESSAY

Do not attach a separate page. Please answer the following briefly in the spaces provided.

What do you consider your most important accomplishment and why? What leadership role did you play?

What do you consider your highest career or academic achievement to date? Briefly explain.

What do you think are the three most critical problems confronting women in your community today and what do you think should be done about them?

Why should you be selected for MILEAD Program?

What do you hope to gain from your experience? List and briefly explain your top three expectations in order of importance to you.

Moremi Initiative is committed to selecting a diverse class of participants that reflects the diversity of the continent in terms of geography, education, class, religion, financial need, or other categories. Also important are diverse political opinions and worldviews. Please briefly characterize how your political views, faith, or other aspects of your “worldview” will contribute to the diversity of the class.

Is there any additional information that you believe would assist the selection committee in assessing your qualifications? If so, describe briefly.

I have read the above and understand the commitment involved in MILEAD participation.

I affirm that all of the information listed on this application is true.

Signature of Applicant and date

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Statement of case for nomination