Title Given name(s) Surname                 

Application made by: Nominee: (provide name below) OR Applicant: (go to section 2)

Nominee Name Nominee Job Title Nominee Organisation                 

Undergraduate Degree Masters PhD

Year completed:Degree

Year completedMasters

Year completedPhD

Relevant professional qualifications:      

Currently Employed in STEM? Yes: No: Sector that best fits with your STEM experience:

Academic: Industry:

Your field: Please selectIf ‘Other’ please provide:      

Name of most recent STEM Employer:      

Job title at most recent STEM Employer:      

Years employed in this role FTE

Total number of FTE years in STEM roles (minimum of 10 years 1.0 FTE in a academic and/or industry STEM sector(s) required)

                 

Are you looking to progress into leadership positions in Australia? Yes: No:

                 

Please respond to the selection criteria below (no more than half a page for each).

4.1 Why do you wish to join the Leading the Way stream of the 2018 inspiring women STEM sidebyside program for mid-career emerging leaders?

     

4.2 If successful in joining the program – how will you use the skills, experience and networks that you have garnered moving forward?

      

4.3 Discuss your success as a leader or potential as a future leader for women in STEM, including your ability to enhance cultural change as a promoter, supporter and mentor across Australia.

      

Postal Address line 1 Address line 2           

Suburb State Postcode Country                       

Email (must be accessible until 30 November 2018)     

Phone (work) Mobile Phone

           

Australian Citizenship1 Permanent Residency

To which racial or ethnic group(s) do you most identify? We request this to better understand our current information reach and so guide future program advertising and recruitment. If you prefer not to provide this information tick here:      

I, <INSERT FULL NAME HERE>, confirm that the information contained in my application is true and accurate. I agree that, as a condition of my forwarding this application, I permit the release of all materials that I have submitted for the purposes of the selection process. I understand that in the event of being selected for the STEM sidebyside program, my details will be publicised.Furthermore I confirm that my manager at my current employer is aware of my interest to participate in the 2018 STEM sidebyside program, and understand that should my application be successful my attendance at program event activities, to be scheduled throughout the year, will be required, with the first event to be held on: Thursday, 31 May 2018.

CHECK BOX & INSERT NAME AS CONFIRMATION AGREEMENT MADE ON:       /       / 2018

Please provide a URL to your LinkedIn profile below or attach a curriculum vitae of no more than two pages to your application.

LinkedIn URL:      

A PDF of your application must be lodged by 2.00pm (AEST), Friday, 13 April 2018 via the veski website at: veski.org.au/inspiring-women/LTW-app

The file naming protocol to use is: applicant surname_applicant initial_LTW

Applicants will be notified regarding the outcome of their application via email by: Friday, 4 May 2018.

.

1 Australian citizen, or a person who forfeited their Australian citizenship on the acquisition of another citizenship before 4 April 2002 under the now repealed Section 17 of the Australian Citizenship Act 1948, or a person who was forced to renounce their Australian citizenship under Section 18 of the Australian Citizenship Act 1948 in order to retain another citizenship or acquire another citizenship.