LARC Application Form

The Leading Australian Resilient Communities (LARC) program will be open to people who reside or work in North West Tasmania. We will be aiming to pull together a diverse cohort of applicants from North West Tasmania.

"*" indicates required fields

Step 1 of 8 - Personal Details

PERSONAL DETAILS

Name*

First Last

Preferred Name

In different from your first name

Date of birth*

Gender

Gender*

Gender refers to current gender, which may be different to sex recorded at birth and may be different to what is indicated on legal documents.

If other, please specify*

What pronouns do you use?

Mobile number*

Alternative phone number

Email address*

Secondary email address

LinkedIn profile address

Which council area do you live or work in?*

Hidden

zap_id

MORE ABOUT YOU

Do you identify as an Australian Aboriginal and/or Torres Strait Islander person*

How would you describe your cultural background? (Please select up to 2 cultural backgrounds)*

Your cultural background is the cultural/ethnic group(s) to which you feel you belong or identify. This background may be the same as your parents, grandparents, or your heritage, or it may be the country you were born in or have spent a great amount of time in, or you feel more closely tied to.

if other cultural/ethnic group please specify*

Apart from English, in which language(s) could you have a conversation about a lot of everyday things? (Please select as many as apply)*

if other please specify*

What country were you born in?*

Do you consider yourself to have a disability, impairment or long-term condition?*

Please note the definition of disability includes sensory, intellectual, neuro-diverse, physical and mental illness – where the disability is permanent or is likely to be permanent

If yes, do you require any adjustments to be able to participate in this program?*

Have you attended a Future Forum held in July?*

How did you hear about this program?*

who?*

if other, please specify*

WHERE DO YOU LIVE

Residential address

Street Address Suburb State Postcode Country

Postal address

Same as residential address

Use residential address as postal address

Street Address Suburb State Postcode Country

EDUCATION LEVEL

What is the highest level of education you have completed to date?*

EMPLOYMENT

Current employer

Employer name*

Position held*

Of the following categories, which BEST describes your current employment status?*

Employment sector*

Which industry sector(s) are you currently involved in? (Please select as many as applicable)*

if other, please specify

Which Food Fibre and Forestry sub-sector(s) are you currently involved in? (Please select as many as applicable)*

if other, please specify

LEADERSHIP HISTORY

Briefly describe any leadership responsibilities in your work or community experience that you have undertaken. What valuable learning did you gain from your experiences?*

Have you completed any other leadership programs?*

Previously completed leadership programs

Approx Year*

Provider*

Program*

Approx Year

Provider

Program

Approx Year

Provider

Program

COMMUNITY AND EMPLOYER INVOLVEMENT

Please share information about your employment in your region and your community involvement*

Please share how your employment and community involvement supports any of the following in your region; [multiple choice]*

Hold down the control key and select relevant choices

What do you think are the top three issues in your community?*

IMPACT

What impact do you want to have on rural, regional and remote Australia as a result of your participation in this leadership program?*

REFEREE

Please provide details for a referee knowledgeable about your leadership performance and potential. The person should be from your industry or organisation, and we ask that you avoid direct family members. Your referee must be willing to answer a number of questions via an online form. This will be sent to them shortly after submission of your application. We encourage you to speak to them prior so they are prepared.

Referee

Name*

First Last

Relationship to you*

Time known

Organisation name

Job title

Email address*

Mobile

COMMITMENT

Commitment*

I confirm that the information provided in this application is true and correct

I confirm that I understand the time commitment required to participate in this program

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Australian
Australian Aboriginal
Chinese
Croatian
Dutch
English
Filipino
German
Greek
Indian
Irish
Italian
Lebanese
Maltese
Maori
New Zealander
Polish
Scottish
Vietnamese
Welsh
Other cultural/ethnic group (please specify)
Unsure
Prefer not to say

English only
Arabic
Cantonese
Filipino
Greek
Gujarati
Hindi
Indonesian
Italian
Korean
Malayalam
Mandarin
Nepali
Punjabi
Sinhalese
Spanish
Tagalog
Tamil
Urdu
Vietnamese
Other language, please specify

Food Fibre and Forestry
Arts and Culture
Community
Digital Technologies
Education and Training
Energy and Mining, Environment
Financial and Insurance Services
Health Care and Social Assistance
Hospitality and Tourism
International Development and Relations
Legal Services
Manufacturing/Processing
Not-For-Profit
Professional and Consultant Services
Public Administration
Social Enterprise
Sport Lifestyle and Recreation
Telecommunications and Media
Trade
Transport
Other (please specify)