International Management Exchange Program (IMEP) Application Survey

ICMA seeks U.S. applicants to be matched with colleagues in countries represented by ICMA's International Affiliate Organizations. Once you have completed this form, please email Berna Oztekin-Gunaydin at boztekin@icma.org and Shraddha Kharel-Pandey, skharelpandey@icma.org the following:

1. A copy of your resume (include information such as education, professional qualifications, offices held, and employment history).
2. A current staffing chart from your local government.

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* 1. Please list the countries that you would like to be matched with in order of preference. Only 3 choices allowed.

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* 2. General Information

Full Name:

Preferred Name:

Age:

Office Address:

City:

State:

ZIP Code:

Office Telephone:

Home/Cell Telephone:

Preferred Email:

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* 3. Community and Personal Information

Current Employer:

Employer Website:

Position and Responsibilities:

Population of Your Locality:

Population of Metro Area:

Number of Employees:

Number of Employees You Directly Supervise:

Gross Expenditures of Your Locality:

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* 4. Provide a brief description of your employing jurisdiction, including local government services rendered and any other factors about your jurisdiction or the metropolitan region that would be helpful in developing a match.

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* 5. Please describe three important issues facing your locality.

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* 6. Please list three of your most significant professional achievements.

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* 7. Please outline the objectives and issues you would like to pursue during the exchange.

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* 8. Will your partner be traveling with you?

Yes

Maybe

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* 9. If yes or maybe, please list your partner’s name and professional or community interests.

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* 10. If proper arrangements can be made, would you like to bring your children?

Yes

Maybe

N/A

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* 11. If yes or maybe, please list names and ages.

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* 12. Are you requesting financial assistance from one of ICMA’s scholarship funds? Scholarship availability is based on need and funding levels.

Yes

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* 13. Are there personal factors that may need to be addressed, such as health, diet, and smoking preferences? A listing of key leisure interests is also welcome.

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* 14. If successful, I agree to submit a final report to ICMA within 60 days of completing the full exchange. The report will briefly explain how the exchange contributed to my professional development and what impact innovations learned abroad could have on my local government. I also agree to hold ICMA harmless from any liability that may arise from my participation in the exchange.

I Agree

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* 1. Please list the countries that you would like to be matched with in order of preference. Only 3 choices allowed.

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* 2. General Information

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* 3. Community and Personal Information

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* 4. Provide a brief description of your employing jurisdiction, including local government services rendered and any other factors about your jurisdiction or the metropolitan region that would be helpful in developing a match.

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* 5. Please describe three important issues facing your locality.

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* 6. Please list three of your most significant professional achievements.

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* 7. Please outline the objectives and issues you would like to pursue during the exchange.

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* 8. Will your partner be traveling with you?

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* 9. If yes or maybe, please list your partner’s name and professional or community interests.

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* 10. If proper arrangements can be made, would you like to bring your children?

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* 11. If yes or maybe, please list names and ages.

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* 12. Are you requesting financial assistance from one of ICMA’s scholarship funds? Scholarship availability is based on need and funding levels.

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* 13. Are there personal factors that may need to be addressed, such as health, diet, and smoking preferences? A listing of key leisure interests is also welcome.

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* 15. Please type full name and today's date to indicate agreement: