Company STEP 1 General Information Title * Ms. Miss Mrs. Mr. Dr. Prof. Rev. First Name * Last Name * Other Names Date of Birth * Place of Birth * Nationality * Country of Residence * National Identity For Non-Ghanaian Residents: Passport No. Country of Issue Date of Expiration National Identity For Ghanaian Residents: Voter's ID/Passport No. Date of Issue Contact Details Primary Phone Number: * Second Phone Number: WhatsApp Number: Twitter Account/Handle (@): Facebook ID: Email Address * Address City Country * Afghanistan Åland Islands 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, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia 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 Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of 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 Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda 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 Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe STEP 2 Education and Languages Highest Level of Education: * Course of Study: * Name of Institution: * Year of Completion: * Are you Currently Enrolled in the School/ College/University: * Yes No English Language Proficiency: * Basic Intermediate Advanced Other Languages Spoken: STEP 3 Employment/ Professional Experience Employment Status Internship Volunteer Employee Self-Employed Position Title/Rank: Corporate or Official Address: STEP 4 Group Discussion Session Selection Please select two groups. Read the descriptions of each group carefully before making your selection * GROUP ONE (1) - Women in Politics GROUP TWO (2) – Women as Entrepreneurs GROUP THREE (3) –Higher Education for the Girl Child/ STEM GROUP FOUR (4) – Sexual Harassment in Schools GROUP FIVE (5) - Environmental Protection and Sustainable Development GROUP SIX (6) - Culture and Change for Development STEP 5 Parallel Section Selection List of tracks representing the various topics that would be discussed during the parallel sessions is outlined and each applicant is expected to select at most, two tracks that they would want to join in. * Track 1: Politics/Leadership Track 2: Business and Commerce Track 3: Social Inclusion/Intervention Projects Track 4: Sexual Harassment and Teenage Pregnancy Track 5: Education and Training STEP 6 Supplemental Questions Responses to these questions are optional. No selections will be made based on this information. This information is used to better understand the people we are dealing with. The aggregate information collected through this form will be kept private and confidential. Marital Status Married Single Divorced Religious Affiliation Christianity Islam Buddhism Hinduism African Traditional Religion Other Disability Yes No Other Leadership Courses - Have you previously participated in a leadership or women empowerment course or training or conference? Yes No Are you a member of the ExLA Group Network Yes No How did you learn about ExLA Group and Young African Women Congress? Social Media & Online Ads Newspaper & Print Website Friend or Referral Partner Organizations & Media Houses Street Billboards Recommend this congress to a Friend Full Name Email Address Telephone Number Consent and Commitment Agree to continue AG In order to participate in the ExLA Group Gender Programme’s Young African Women Congress, I understand that I must meet the minimum eligibility requirements for admission to the programme, that I must pay the required registration fees, that I must meet the qualifications standards for the specific group that I have chosen, that I must be a young woman within age 18 – 45, and that my admission to the programme is subject to the determination by the Selection panel. I have read, understood, and will comply with the terms and conditions of the congress. I hereby certify that I have completed this application fully and accurately to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to disqualification AG1 I hereby acknowledge that if accepted as a participant in the Young African Women Congress 2018, I confirm that I will abide by the time commitment as outlined in the full 5 Day programme.