HCEO Application 1 – Contact InformationPlease complete all five sections of the HCEO 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. 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneFAXEmail* 2 – 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 TitleBusiness RelationshipPhoneEmail Reference #2 Name First Last Job TitleBusiness RelationshipPhoneEmail 3 – 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*4 – 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 proposed certificate course focus: • Given your current professional situation, which courses do you think you want to focus on — Your potential contribution to the HCEO 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.5 – Sign ApplicationPlease sign and date the application in the box below. Type your name, then submit the completed application.Please Sign Here*Date* MM DD YYYY 6 – Submit Application
