ERG Leadership Certificate Application Please complete all seven sections of the ERG application and return it to the Center for Effective Organizations. The admissions committee will review your application and respond within two weeks of receiving a completed application.1 – Contact Information Dr. Ms. Mr. Name* First Middle Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Job Title* Company Name* Business Phone*Mobile PhoneFAXEmail* 2 – ERG LeadershipDo you have experience as an ERG leader? Yes No If yes, what type of ERG ?3 – RecommendationsApplicants must be recommended to the program. Please list the names of two executives in your organization who are familiar with your skills and potential. Please inform them that we will be contacting them to discuss your candidacy.Reference #1 Name First Last Job Title Business Relationship PhoneEmail Reference #2 Name First Last Job Title Business Relationship PhoneEmail 4 – Job Experience and Educational BackgroundPlease provide the following information in resume format: – A brief description of your current and previous jobs including: • Your job responsibilities, reporting relationships, and the city/country where the work took place • Any involvement or awareness of the strategic planning process at corporate, region, or business unit • Degrees, certificates, and management or executive development experiences Upload Resumé*Max. file size: 100 MB.5 – Open-ended QuestionsPlease address the following questions below. Upload a PDF file using the link below. — Your Motivation: • What attracted you to this certificate program? • What are your career goals? • What do you want to get out of the certificate? • What issues are you confronting in your organization that you would like to address? — Your potential contribution to the ERG community of practice: • A critical part of the certificate is a community of practice (COP). • What do you bring to the community? • What do you consider to be your areas of expertise? • In the past year, what books, movies, or experiences have most influenced your practice? Upload File*Accepted file types: pdf, Max. file size: 100 MB.6 – Sign ApplicationPlease sign and date the application in the box below. Type your name, then submit the completed application.Please Sign Here* 7 – Submit ApplicationDate* Month Day Year Δ
