Savings Groups: Building Scale and Impact Through Adaptation and Experimentation

Savings Groups: Building Scale and Impact through Adaptation and Experimentation A Blended Online Online Course Application Form

First Name Family Name Date of Birth Gender Name of Course Building Scale and Impact through Adaptation and Experimentation A Blended Online Course for Savings Groups Professionals

Date of Course June 15 – October 23, 2015

Your Personal Contact Information Street Address City Province/State Country Postal Code *Primary Phone # *Secondary Phone # Cell or Landline Cell or Landline Primary Email Fax Secondary Email Skype Address *Please include your, country code, area code and full phone number. Sometimes there is a difference for cell phones. See this link for reference: http://www.wikihow.com/Dial-International. If your country is not listed, then get in touch with your cellphone provider.

Your Work Experience Job Title Level of Responsibility Within Your Organization Senior Management (example, managing a region or organization) Middle Management (example: field coordinator, project manager) Entry Level (example: extension worker, assistant, intern, other) Your current role and responsibilities:

Organization Name Website of Organization Organization Street Organization City Country Postal Code Telephone Mobile Phone Email Fax Type of Organization. Please choose one. International NGO National NGO Local Association or cooperative Local NGO Government Body Donor Consultant / Private Sector Academic / Research Network Other (please explain):

How many years of relevant work experience do you have related to savings groups or member-owned microfinance?

Your Education Secondary Certificate Diploma School BA/BSc Masters PhD Other training and Professional Development regarding microfinance, savings groups or relevant content Dates Attended Name of Course Institute/Training Provider

Savings Groups: Building Scale and Impact through Adaptation and Experimentation: 2

A Blended Online Course for Savings Groups Professionals

Online Course Application Form Savings Groups: Building Scale and Impact through Adaptation and Experimentation: 3

Online Course Application Form How will your participation in this course affect greater change in your personal career, organization and sector?

Access to Internet and Online Experience

As this is an Online course, we would like to adapt our delivery of the course to your internet accessibility. What type of Internet access do you have? High Speed Reliable High Speed Intermittent Low Speed Reliable Low Speed Intermittent Dial Up Reliable Dial Up Intermittent Please number all of the following devices that you will use for this course marking 1 as your primary device: Personal Tablet Personal Work Tablet Personal Computer Work Computer Shared Family Work Shared Work Computer Computer Cell Phone Other

What is your experience with online learning?

I have done searches I have taken an online online but never a course before discussion, webinar or course I have participated in at I have facilitated an least one webinar online discussion or webinar I have participated in at I have facilitated an least one online online course discussions or listserve discussion

Online Course Application Form Please tell us how you found out about the SMDP Online at the Carsey School of Public Policy and its programs. Check all that apply.

From a staff person in your organization From a SMDP Alumni Name of Alumni Saw an advertisement Where did you see this ad? In an e-mail from the Carsey School of Public Policy MaFi BEAM Exchange, LinkedIn SEEP On the internet Please specify Other Please specify

Have you attended any other SMDP programs? Yes No If yes, did you receive a SMDP scholarship? Yes No If yes, how has your work/position changed since then?

Tuition Payment Information

Full tuition for this course is USD $2,500.00

Please describe how you will make payment for tuition – Check correct box Wire Transfer Credit Card Check from U.S. Bank

PAYMENT INSTRUCTIONS Students will make payments directly to the Carsey School of Public Policy/University of New Hampshire in U.S. dollars and can pay by check from a U.S. bank, credit card, or wire transfer. Credit card payments are subject to a 2 percent processing fee on the total transaction amount. Please note that if payment is made by wire transfer, you must add $35 for the wire transfer fee. A deposit of $500.00 is due within 10 days of registration. The balance of tuition must be paid by the registration deadline May 22, 2015 Check Please make payable to: University of New Hampshire/SMDP and mail with a copy of this registration to: Carsey School of Public Policy/SMDP New Hampshire University of New Hampshire 73 Main Street, Huddleston Hall

Online Course Application Form Durham, NH USA 03824 Wire Transfer Please contact the SMDP Registration Manager for wire transfer instructions [email protected] Be sure to include your name on the draft and send us an email or fax letting us know that it has been processed. Please add a $35 fee to cover the cost of the transfer and other bank charges. Note, there is no standard rate for such costs and therefore it may vary from the recommended $35. In such a case, if your payments are either short or greater than the amount you owe, we will settle it while you are at the school. The payment amount will be based on the notification we receive from our bank as to what the actual deposit is, therefore make sure you correspond with us at [email protected] regarding this. Credit Card If you wish to pay by credit card, please contact the SMDP office at [email protected] or call 01-603-862-3603 and we can take your card information over the phone. We will initially charge a $500 plus 2% processing fee ($10) for a total deposit of $510 to your card for each person you register upon receipt of your registration(s). The remaining balance will be charged against your card before you begin the course. Once your deposit or full payment has been received, we will send you an email confirmation. For payment questions, contact [email protected] or call 01-603-862-3603 (Fax 01-603-862-3878).

MasterCard Foundation Scholar Applications If you complete the MasterCard Foundation Scholarship section below and commit to paying a share of the tuition for your course, you will be required to make this payment as soon as you have been accepted to the program. If you do not make the payment within two weeks of notification of your award, you may forfeit your scholarship opportunity.

Refund Information: If you cannot attend the SMDP Online course, you may request a refund in writing or via email. Requests received before June 30, 2015, will be refunded in full, less a $100 processing fee. There will be no refunds for cancellations received after that date. It can take up to 4 weeks once you request a refund for payment to be processed. The refund will be remitted in the form it was received. For example, credit card payments will be issued a credit back to the original card the charge was made on (due to credit card regulations we are unable to make exceptions to this policy), and wire transfers will be refunded via wire.

Online Course Application Form The MasterCard Foundation Scholarship Application SMDP Online Spring-Summer 2015 Deadline for Application Submission May 22, 2015

Please read the eligibility information below carefully and do not apply for a scholarship if you do not meet most of the stated criteria. Your entire application will be rejected if you do not meet most of the listed criteria. Please check all that apply.

Recommendation Criteria: Scholarship recommendations will be determined by the following criteria: o How well does the applicant meet the eligibility selection preferences listed? o Based on the candidate’s stated background profile, how would the scholarship make an impact on her professional development and to the organization?

Scholarship Eligibility Criteria and Statement I am applying for scholarship support from the MasterCard Foundation Microfinance Scholars Program scholarship program and I certify that the following information is true. I have not previously received a scholarship from the MasterCard Foundation I am a practitioner with at least two years’ experience in the course topic I am a woman I primarily work in Africa I work for an NGO, development finance institution, policy development organization, or private firm. My background can be described a disadvantaged from rural and/or a resource-poor area I can make a contribution of at least 10% of the tuition fee Please state amount of contribution I agree to make the contribution amount stated above by the program deadline if my scholarship application is approved.

Admissions Office Please email the complete application to SMDP Online Carsey School of Public Policy [email protected]

Online Course Application Form