Please note that this form must be fully completed once you start, it cannot be saved and re opened at another time. So please ensure you have all the relevant details and enough time to complete the application form in full.

Also please note you will require the contact details of two referees to complete the form.

If you have any questions about this form or the program in general, please give me a call on 0429 22 00 69

Thank you
Rod Robinson
Program Manager
What's your first name? *

Hey {{answer_28300633}}, nice to meet you.
What's your last name?

What's your mobile number?

What's your birth date?

What address should we send any snail mail to?

Which town do you live in?

Which Shire do you live in?

Which sector do you work in?

Have you applied to the program before?

Who is your present employer? (if you are currently employed.)

What is your job title?

Briefly describe your role and your major responsibilities please.

Briefly describe some of your major life experiences for us.

What are some of your goals for the future? These may be work, community or family related.

What do you hope to gain for yourself from participating in the Northern Mallee Leaders program?

How do you expect your community will benefit from your involvement in the Northern Mallee Leaders Program?

Do you have any hobbies/activities that you do for enjoyment?

Ok, thanks for sharing a bit about you - now some thoughts on the region you live in.

Northern Mallee Leaders aims to develop a network of community leaders across the region to enhance the decision making and leadership skills by sharing experiences and working together.

When you think about your community and the Northern Mallee Region what is your fondest aspiration or greatest hope?

When you think about your community and the Northern Mallee Region what issue concerns you the most?

Thanks, now your community interests.  Tell us a bit about them please.

What are your community interests?

Do you contribute to any community organisations?  If so what are they?

Are there any you would like to contribute to?

Do you have any thoughts/ideas on community projects that you might like to develop as part of your involvement in Northern Mallee Leaders?

We would love to talk with someone who will speak about your skills and attributes.  Can you please list two referees, one an employer if you are employed and one who can speak about your community involvement?

Referee 1



Best Phone Number

What can this person speak on your behalf about?

Referee 2



Best Phone Number

What can this person speak on your behalf about?

You may like to seek out your own scholarship or financial support for the program.  NML offers a select number of scholarships for people who may need assistance to meet the participation fee or are supported to ensure diversity exists in our program.
Please indicate if you believe you may be eligible for the following scholarships.

Are you eligible for the following scholarships?

Participation and Commitment:

Successful applicants will be required to commit themselves to full participation in the program, this includes
- Attending all compulsory activities
- Attending at least 80% of all other activities
- Completing the required evaluation after each day and
- Completing and reporting on a community project (one that is achievable and of benefit to the community), it is desirable that this community project be completed within six months of graduation.

NMLP is funded primarily through sponsorship. There is a non refundable participant fee of 
Community organisations and volunteers $1,650 (inc GST)
Corporate Organisations $2,750 (inc GST)
Participant fee* $ 220 (inc GST) 
*payable by individual is sponsored by an employer or is a scholarship recipient

This represents a small component of the overall cost (30%) and demonstrates commitment to the program.

Program days are conducted in a variety of places across the region to increase awareness of the region and its resources. This can involve considerable travel and long days. in the interest of safety, NML strongly encourages car pooling with fellow participants and overnight accommodation when appropriate. Travel to and from program days and accommodation other than scheduled overnight stays will be at the participants own expense.

If accepted into the program I agree to pay the appropriate fees as my contribution to the program.

If accepted into the program I agree to attend the compulsory program activities listed in the program calendar.

If accepted into the program I am committed to attending all the program activities and an absolute minimum of 80%.

If accepted into the program I agree to share car pooling and accommodation during program activities.

If accepted into the program I agree to undertake a community project within six months of graduation.

I understand and agree with the goals, time commitments and fees associated with the Northern Mallee Leaders Program.  I have talked with my family and employer and they are aware and agree to my application.

Wow, you've made it to the end of the application form.  Great Job and thanks for applying.  We will be in contact with you during the first week of November to discuss what happens next.

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