PERSONAL INFORMATION

First Name:


Last Name:


Date of Birth:


Age:

CONTACT INFORMATION

Contact Address:


Mailing Address (if different from above):


Phone Number:


Your Email Address:

CURRENT BACKGROUND

Are you currently working or in school?:

• Name of School:
  

• Subject & Degree (e.g. OND, HND, BSc, MSc, etc):
  

• Year/Level:
  

• Name of Employer/Organisation:
  

• Position:
  

• Nos. of Years in Organisation:
  

• What does the organization do?
  

• Does this organization target/provide services for women?
  

  • If so, how?
    

• Estimate the proportion of women (%) working in the organization. What proportion (%) of the female workforce occupies high-level/managerial positions?
  

• If you are neither working nor in school, provide information regarding how you occupy your time. Estimate the number of hours you spend on each of the various activities.
  

SOCIAL INVOLVEMENT

Describe your involvement with social development and/or community-centred programs. Please be as specific as possible regarding the objectives and achievements of the programs. Highlight your contributions to each of the programs.

Program:

• Objective:
  

• Position:
  

• Your Contribution:
  

• Dates:
  

• Objective:
  

• Position:
  

• Your Contribution:
  

• Dates:
  

• Objective:
  

• Position:
  

• Your Contribution:
  

• Dates:
  

• Objective:
  

• Position:
  

• Your Contribution:
  

• Dates:
  

EDUCATIONAL BACKGROUND

Secondary School:

• Name:
  

• City, State:
  

• Year Graduated:
  

• Name:
  

• Subject & Degree:
  

• Year Graduated:
  

• Name:
  

• Subject & Degree:
  

• Year Graduated:
  

• Name:
  

• Subject & Degree:
  

• Year Graduated:
  

TECHNOLOGY SKILLS

Give details of your technology skills e.g. knowledge of applications (list them), networking, hardware, desk top publishing, web development, graphic and/or multimedia development, programming languages, etc.

Skills/Applications:

• Level of Proficiency (Beginner, Intermediate, Advanced):
  

• Nos. of Years Experience:
  

• Level of Proficiency (Beginner, Intermediate, Advanced):
  

• Nos. of Years Experience:
  

• Level of Proficiency (Beginner, Intermediate, Advanced):
  

• Nos. of Years Experience:
  

• Year Obtained:
  

• Year Obtained:
  

• Year Obtained:
  

KNOWLEDGE TRANSFER

How do you feel that this W.TEC program would benefit the work you do?


What are the specific tools or techniques that you would like to learn, if any?


Why do you feel that it is important that women are engaged with technology? What part do you envisage that you can play in helping to achieve this?


How do you intend to disseminate your knowledge and skills gained from this program with other women (in your organization, community, family, etc)?


What are the professional goals that you have set for yourself to achieve within the next five years?


Why do you think that you are suitable for this programme?

REFERENCES

Provide names and contact information for two references (who are not related to you).

Referee Name:

• Contact Address:
  

• Mailing Address (if different from above):
  

• Phone Number:
  

• Email Address:
  

• Relationship with you:
  

• Contact Address:
  

• Mailing Address (if different from above):
  

• Phone Number:
  

• Email Address:
  

• Relationship with you:
  

ADDITIONAL IMPORTANT INFORMATION

The Networking for Success programme will run for 1 month. During this time, participants are expected to contribute to online discussions and attend weekly workshops.

Can you commit to the following?

Contributing to online discussions every week:	Yes	No	Maybe
Attending weekly workshops:	Yes	No	Maybe
Arriving on time for the seminars:	Yes	No	Maybe
Not missing any session:	Yes	No	Maybe
Demonstrating interest in the program through active participation in discussions, assignments and team work:	Yes	No	Maybe

How did you hear about this program?