Executive MBA Application Form 2000

DATA SHEETUniversity of Cape Town

Graduate School of BusinessBreakwater Campus, Green Point, 8001

Cape Town, South AfricaTelephone: (021) 406 1322

Telefax: (021) 406 1446International Telephone: +27-21-406 1322

Telefax: +27-21-406 1446Patsteyn@gsb2.uct.ac.za

PersonalFamily Name Given Name(s) Name by which you are usually known

Title Date of birth SA Citizen/Permanent Resident: Yes/No ID Number : (If no) Nationality Passport No :

Company/Organisation:

Address:

Postal Code:

Home Address:

Postal Code:

Fax:

Telephone No: (Home) ( Work)

Cellular E-mail

APPLICATION FEE (NON REFUNDABLE) SA R450(within SA) US$ 200 (outside SA) Cheque/money order Visa/Master card(Attach your Application fee cheque here) Card Number

Expiry Date / /

I authorise UCT to charge my credit card with the amount of : R450 / $US200 CARD HOLDER’S NAME (Please print) Cardholder’s signature

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Executive MBA Application Form 2000

Employment Profile

Please type or print in black ink.

Family Name Given Name(s)

1. Present Employer/Organisation

2. Your current position:

3. If you are employed in the private sector,is your organisation a subsidiary?If so, please name the parent company:

Job Function and Company Sector: Please check the table belowJob Function

Finance Control Consulting Corporate Planning R & D Legal General Management Marketing Personnel Management Production Management Systems Analyst Teaching Staff Management Other (please specify)

Company Sector

Agriculture Mining Construction Food and Drink Tobacco Textile Wood Paper Printing & Publishing Industrial Chemicals Other Chemicals Pharmaceutical’s Cosmetics Petroleum Plastics & Rubber

Stone, Clay and Glass Primary Metal Objects Fabricated Metal Objects Non- electric Machines Electronic Equipment Electric Machines Automobiles Aeronautics Other Transportation Optical & Scientific Eqp Misc Manufacturing Prods. Transportation & Travel Communication Energy Wholesale Trade Retail Trade Investment Banking

Commercial Banking Other Finance Real Estate Holdings Computer Service Advertising Other Service Consulting Leisure Service Executive Search Education Soc & Health Service Business Assoc Research Institutions Engineering Services Public Admin

(please specify)

4. Please briefly describe what you do, and what are your principal responsibilities. Who you report to (title)? Do you sit on any board, management committee or equivalent?

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Executive MBA Application Form 2000

Employment Profile

5. Please briefly outline your career history and major accomplishments.

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Executive MBA Application Form 2000

Employment History

Please summatrise your significant work experience over the last 10 years starting with your most recent / current position

Dates From To Job Title/Position Company/Organisation Primary Responsibility

Note: You may use additional sheets as necessary

INTERNATIONAL EXPOSUREPlease list international exposure and activities

ACTIVITY No of Years

Country/Region

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Executive MBA Application Form 2000

Education and Activities Profile

Education:List in chronological order colleges and/or universities attended:

Institution and location Dates of attendance Degree/Qualification and year received

19 to 19

19 to 19

19 to 19

19 to 19

19 to 19

How would you rate your competence in the following mathematics and computer skills areas?(a) No experience (c) Need some refreshing in order to be proficient.(b) Some previous experience (d) Am proficient and do not need refreshing.

but out of date. a b c d

AlgebraStatisticsPC skill (i.e. word processing, spreadsheets)Internet

Languages :English : fluent good average Mother tongue:Other :

Extra-Curricular Activities:Please list below, in order of importance to you, all significant extra-curricular activities in which you have been involved and made a significant contribution i.e. (educational, community, professional, sport, politics, associations, etc). Attach additional sheets if necessary.

Activity Dates Description of your contributionto

to

to

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Executive MBA Application Form 2000

Education and Activities Profile

Professional and vocational qualifications (non-university):

Membership of professional associations/committees:

What other training and development courses have you attended?

What are the capabilities you have developed most through job experience?

Do you have any other accomplishments, experience or skills that you would like to be taken into consideration in support of this application?

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Executive MBA Application Form 2000Information

We encourage applicants to learn as much as possible about the University of Cape Town, Graduate School of Business and to consider the impact of studying for an EMBA on their family and friends. With whom have you discussed your plans to undertake EMBA studies and what were their responsibilities? (Please give names of any alumni, students, faculty or staff of the UCT Graduate School of Business if applicable).

Do you see any possible difficulties in attending the EMBA Programme?

We would be grateful if you could help us with our marketing by answering this section.

Where did you hear about the UCT EMBA programme? (Please specify)

Advertising publication : Work : whom :

Direct Mail : when Internet :

Conference/Course which :

GSB publicity presentation where :

From a GSB alumnus/former student who :

Other :

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Executive MBA Application Form 2000

EssaysPlease type or print in ink.

Family Name Given Name(s)

We would like to learn more about you. Please write on each of the following topics:

Note: Write each essay on a separate sheet(s) of paper. Staple them to the back of

this form and return them with this application.

Your essays should be typed (1½" line spaced) or written legibly.

Each should be no more than 300 words.

Please write clearly and openly about yourself.

Please answer all the questions

Topics 1 What are your goals in life? Where do your work goals fit into this? How would you like to be remembered?

2 Imagine yourself in 15 years time from now. Looking back to to day, explain why you wanted to do an EMBA at this time, and how it contributed to your development and career.

3 How will you complete the EMBA programme and at the same time carry on with and successfully manage family/personal commitments over the next two years? What will be your greatest challenges and how do you plan to cope with them?

4 You will have to work in groups during the process of your EMBA. What do you think you can offer the group process? What do you think you need most to work on over the next two years, in terms of, helping you to work with others in groups?

Statement of IntegrityI hereby certify that I have provided accurate information in this application. I authorise all persons or entities to provide any relevant information in their possession to the University of Cape Town or its agent for use in considering me for admission or verifying my credentials for admission, and I expressly waive any required notice to me. I understand and agree that any misrepresentation or omission of facts in my application will justify the denial of admission, the cancellation of admission, or expulsion. This application is my own, honest statement to the Admissions Committee.

Signature Date

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Executive MBA Application Form 2000

Financing Your EMBA

Participants are expected to take full responsibility for financing their EMBA and to manage their own financial affairs. You should establish your financial plan according to the following expected payment dates:

1. Non-refundable Application Fee (to accompany application form) R450 (SADC) US$200( non-SADC)

2. A candidate who has applied for admission will be required to pay a deposit of R5,000 for the 2000 academic year at the time he/she is made a firm offer of a place. Failure to do so by the date given in the letter of offer may result in the cancellation of the offer. This deposit will be credited to the student’s fees account and will form part of, and not be in addition to, the amount payable on or by 19 February 2000. The deposit is not refunded to a candidate who subsequently withdraws his/her acceptance of the place offered. Hence this is a minimum fee payable by any student who accepts an offer of a place, even if the student decides not to study at UCT at all.

3. Tuition fees are payable annually in advance. The first payment is due on or before 19 February 2000 which is equal to 50% of the total fees due, less the deposit of R5000. Payment of the balance of fees is due on or before 15 January 2001 and will be rendered in terms of a detailed statement of account.

Total fee for year 2000 intake. These are fees for the two-year period and for SADC applicants:

Initial payment on acceptance R 5 000 (deducted off first year payment)Tuition fees R62 000Books & amenities fees R18 000Accommodation (bath-en-suite) R19 697 ORAccommodation (share-shower) R17 260

Does your employer know you are applying to the University of Cape Town, Graduate School of Business? Yes No

Have you discussed with your employer the time and financial requirements for an Executive MBA?

Is your employer willing to support you by Time Tuition fees Both

Is your employer prepared to provide you with facilities/access to undertake an in-company consulting project during the final year of the programme?

Yes No To be confirmed.

Please give details of how you propose to pay for the course:

Fully sponsored by employer Own funds Partially sponsored by employer Bank loan Applying to employer for sponsorship other (please specify)

Will your company pay you a salary while at GSB? Yes No MaybeAre you obliged to return to this company? Yes No Maybe

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Executive MBA Application Form 2000

Confidential Evaluator’s Form

Name of Applicant

Family name Given name(s)

You may solicit more than the two required evaluations if, in your opinion, the information they provide would significantly strengthen your application.

Evaluator: Please complete the information requested on both sides of this form. If you use additional sheets of paper, please staple them in the back of this form.

Please mail this form to The Executive MBA Administrator, Graduate School of Business, University of Cape Town, Breakwater Campus, Portswood Road, Green Point 8000, Cape Town, South Africa.

How long have you known the applicant?Under what circumstances have you known the applicant?

In making your evaluation of this applicant, with what reference group are you making your comparisons?

Note to Evaluator: Kindly be candid in your evaluation. UCT is an educational institution that is committed to developing and improving peoples’ capabilities. We do not expect applicants to excel in all areas before coming on the EMBA. We need an accurate and balanced picture of the candidate’s strengths and weaknesses so that we can judge whether he/she and his/her sponsoring organisation will benefit from the education offered on the EMBA programme.

Outstanding

(Top 2%)

Extremely Competen

t (Top 10%)

Very Capable

(Top 30%)Averag

eRequires

development

Professionalism

Creativity

Maturity

Empathy with others

Sense of humour

Taking initiative

Analytical skills

Verbal skills

Energy and determinationAbility to work with others in teamsAbility to work alone

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Confidential Evaluator’s Form (Continued)

Please provide by completing the grid below, an overall estimation of the applicant’s potential in the following areas:

Exceptional High AverageUnlikely to achieve more than average

success

Academic successLeading & motivating othersSuccess in business/organisations

How will the EMBA degree contribute to the candidate’s managerial advancement in your organisation (or their career)?

Please discuss any weaknesses the applicant may have and specify the efforts, if any, the applicant has made to improve in these areas.

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Confidential Evaluator’s Form (Continued)

Please elaborate on the ratings you have assigned above, either in the following space or in a separate letter and comment on how the applicant might contribute to the programme. Please feel free to make any further points, such as an assessment of strengths and weaknesses, which you feel will be helpful.

Please indicate with a cross below to illustrate your recommendations for this candidate:Not recommended Reapply later Recommended Highly recommended

Evaluator’s signature Date

Evaluator’s name (print)

Evaluator’s Position/Title

Evaluator’s organisation

Phone ________________________________ Fax ________________________________________

Street address City

Postal code Country

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