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Expert Registration Form
Expert Registration Form
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PUBLIC PROFILE INFORMATION (to be shared with public)
To be completed by the Expert and returned to the PLRCAP program with the signed cover letter.
Picture Upload
*
Click or drag a file to this area to upload.
Maximum file size: 500kb
Individual or Company Name:
*
Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
This will be shown on your profile
State
Abia
Adamawa
Akwa Ibom
Anambra
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Ebonyi
Edo
Ekiti
Enugu
FCT - Abuja
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nasarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
This will be shown on your profile
Areas of Expertise (choose all that apply):
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Leadership
Strategic visioning and planning
Effective governance
Human resource and Finance management
Resource mobilization
Project development and implementation
Communications and branding
Partnership and network building
Organizational development and Change management
Facebook Link:
*
Twitter Link:
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LinkedIn Link:
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Company/Individual Pitch: (5 lines) To appear on your public profile
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Types of Services: Mentorship, Coaching, Annual course application based (serves check out website)
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Fees if any (please as much detail as can… hourly fee)
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Other organizations worked with:
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How to connect:
Any other information you would like to provide to us?
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APPLICATION INFORMATION (For Internal Use)
Personal Information:
Full Name (individual):
*
Organisation Name (Company):
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Email Address:
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Password
*
Password
Confirm Password
Phone Number:
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Address:
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City:
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State:
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Professional and Educational Background:
Current Job Title:
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Current Employer/Organization:
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Years of Professional Experience:
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Educational Background:
Degree(s) Obtained:
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Institution(s) Attended:
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Graduation Year(s):
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Mentorship and Coaching Interests and Expertise:
Which area are you applying to be a Mentor and/or trainer for? (Choose all that apply)
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Leadership
Strategic visioning and planning
Effective governance
Human resource and Finance management
Resource mobilization
Project development and implementation
Communications and branding
Partnership and network building
Organizational development and Change management
What other areas or topics are you interested in training and/or mentoring in?
Please describe your expertise and experience in these other areas you are interested in (fill summary below and attach CV and Cover Letter).
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CV and Cover Letter Upload
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Mentorship Availability:
How many mentees are you willing to mentor simultaneously in a class? (Typically, we would have 4-6 individuals per session)
1-5
6-10
11 and above
How many hours per month can you commit to mentoring? (Typically, we expect you to commit a minimum of 12 hours a month to the mentorship program)
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What is your preferred method of communication with mentees? (Video Calls and emails is mandatory. Choose any other that applies)
In-person meetings
Video calls
Phone calls
Email
Other
Please specify
Mentoring Philosophy:
Please describe your mentoring philosophy and what you believe makes a successful mentorship relationship.
Previous Mentorship Experience:
Have you previously served as a mentor in any capacity? If yes, please briefly describe your experience.
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References:
Please provide the contact information for two professional references who can speak to your qualifications and character.
First Referee's Name
First Referee's Email
*
First Referee's Phone
Second Referee's Name
Second Referee's Email
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Second Referee's Phone
Please provide the contact information for two organizations you have trained or mentored who can speak to your qualifications and character.
First Organization Name
First Organization Email
*
First Organization Phone
*
Second Organization Name
Second Organization Email
*
Second Organization Phone
*
Declaration
I hereby declare that the information provided in this application is true and accurate to the best of my knowledge.
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