2012 APPLICATION FORM - Antigua and Barbuda

LEADERSHIP THROUGH EXCELLENCE AWARD PROGRAMME (LEAP)
2012 APPLICATION FORM
The Application Form must be completed and submitted no later than September 29 th 2012.
Please give a rationale in the box below why you are applying for an Award, and your career
goals stating particularly how training as a LEAP Awardee will allow you to contribute to the
development of Antigua and Barbuda). (Add lines in box if needed)
A. General Information:
1. a) Name in full
___________________________/____________________________/______________________
First Middle Last
b) Gender _____________________ c) Marital Status ____________________________
2. Nationality _____________________________________________________________________
3. a) Date of Birth _____________________ b) Age (at last Birthday) _________________
DD/MM/YYYY
c) Country of Birth ______________________________________________________________
4. Mailing Address ________________________________________________________________
_______________________________________________________________________________
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5. Telephone number(s) ____________________________/________________________________
Home
Mobile
6. E-mail Address __________________________________________________________________
B. Applicant’s Qualifications:
13. Secondary/High School Exam Board /Subject /Grade /Year
Educational Institution
_________________________________________________
____________________
_________________________________________________
____________________
_________________________________________________
____________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
14. Higher Educational Institution Certificate /Diploma /Degree /Year
__________________________ _________________________________________________
__________________________ _________________________________________________
__________________________ _________________________________________________
15. Other
__________________________
__________________________
__________________________
__________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
16. Name of preferred Ministry/Ministries for attachment (2 maximum)
_______________________________________________________________________________
_______________________________________________________________________________
17. Department/s of this Ministry/these Ministries preferred (2 maximum)
_______________________________________________________________________________
DECLARATION BY APPLICANT
I declare that the statements contained in this application are, to the best of my knowledge, true and
accurate. I authorize the administrators of the LEAP to seek verification of the information provided for
the purposes of determining whether to approve this application
Date completed
_______________________
DD/MM/YYYY
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If your application is approved, you will be asked to submit the following documents to the Ministry of
Finance:
DOCUMENTS:
i. Recent Passport-sized photo
ii. Certified copy of photo page and date of expiration page of Passport
iii. Certified copy of your birth certificate
iv. A certified copy of your academic certificate/diploma/ degree
Please e-mail the completed form to one of the following addresses:
raecollis@gmail.com or
gimhoffgordon@gmail.com
** Deadline for submitting this application form is Sep 29, 2012
This Space for Official Use Only
Authorized Signatures:
Coordinator: ____________________________________
Date:_____________________
DD/MM/YYYY
Permanent Secretary: ____________________________
Date:_____________________
DD/MM/YYYY
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