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Aussa Research Institute: VORTEX-PMC+™ Certification Track Intake Form
Thank you for your interest in the VORTEX-PMC+™ Certification Track (Value-Oriented Resilience, Transformation, Execution, and Cross-Disciplinary Portfolio-Project Management Certification). This form collects essential information to begin your enrollment process, assess your eligibility, and tailor your training experience to your career goals. The program equips you with skills in project and portfolio management (PPM), energy innovation, policy advocacy, and interstellar governance, aligning with global priorities like SDG 7 and AU Agenda 2063. Please complete all required fields (*) and submit the form to start your journey with Aussa!
Submission Instructions:
Complete the form digitally (fillable PDF or online via www.aussaresearch.com).
Email to training@aussaresearch.org or submit through the Aussa website.
Contact our team at training@aussaresearch.org or +1-202-555-1234 for assistance.
Priority deadlines: 30 days before program start (January, April, July, October 2025).
Section 1: Personal Information
Full Name (First, Middle, Last):
[______________________________]
Preferred Name (if different):
[______________________________]
Email Address (primary contact):
[______________________________]
Phone Number (include country code):
[______________________________]
Country of Residence:
[Dropdown Menu: Select Country]
City/State/Region:
[______________________________]
Are you part of the African diaspora? (Optional, helps tailor community engagement)
[ ] Yes [ ] No
If Yes, specify community or heritage (e.g., Ghanaian, Nigerian, Caribbean):
[______________________________]
Preferred Language for Training (select all that apply):
[ ] English [ ] French [ ] Amharic [ ] Other (specify): [______________________________]
Section 2: Professional Background
Current Occupation/Job Title:
[______________________________]
Organization/Employer:
[______________________________]
Industry/Sector (select one):
[ ] Energy & Sustainability [ ] Government & Civic [ ] Technology & Innovation
[ ] Academia & Research [ ] Health & Life Sciences [ ] Defense & Aerospace
[ ] Non-Profit/NGO [ ] Other (specify): [______________________________]
Years of Professional Experience:
[ ] 0–2 years [ ] 3–5 years [ ] 6–10 years [ ] 10+ years
Highest Level of Education:
[ ] High School Diploma [ ] Associate Degree [ ] Bachelor’s Degree
[ ] Master’s Degree [ ] Doctorate [ ] Other (specify): [______________________________]
Field of Study:
[______________________________]
Relevant Certifications (e.g., PMP, PRINCE2, Agile, ESG):
[______________________________]
[ ] None
Brief Description of Current Role and Responsibilities (max 150 words):
[Text Box: ___________________________________________________________]
Section 3: Program Selection
Which VORTEX-PMC+™ Certification Level Are You Applying For? (Select one)*:
[ ] VORTEX-PMC Associate™ (Level 1, $2,000, 2 weeks, Entry-Level)
[ ] VORTEX-PMC Practitioner™ (Level 2, $3,000, 3 weeks, Project Managers)
[ ] VORTEX-PMC Strategist™ (Level 3, $4,000, 4 weeks, Program Managers)
[ ] VORTEX-PMC Architect™ (Level 4, $5,000, 5 weeks, Portfolio Managers)
[ ] Specialty Track (Agile, Tech, Public Sector, ESG, $3,000, 3 weeks, Sector-Specific)
If Specialty Track, specify: [ ] Agile [ ] Tech [ ] Public Sector [ ] ESG
Preferred Program Start Date (select one):
[ ] January 2025 [ ] April 2025 [ ] July 2025 [ ] October 2025
[ ] Flexible (online course, year-round)
Preferred Delivery Format:
[ ] In-Person Bootcamp (D.C., Addis Ababa, Accra, Cape Town, Lagos)
[ ] Online Course [ ] Hybrid (in-person and online)
If In-Person, preferred location: [Dropdown: D.C., Addis Ababa, Accra, Cape Town, Lagos]
How Did You Hear About VORTEX-PMC+™? (Select all that apply):
[ ] Aussa Website [ ] Social Media (X, LinkedIn) [ ] Diaspora Network (e.g., DAF)
[ ] Partner Organization (e.g., UCT, MIT, Strathmore) [ ] Funder (e.g., AfDB, World Bank)
[ ] Colleague/Friend [ ] Other (specify): [______________________________]
Section 4: Goals and Interests
Primary Goal for Enrolling in VORTEX-PMC+™ (select one):
[ ] Career Advancement (e.g., promotion, new role)
[ ] Skill Development (e.g., PPM, energy innovation, interstellar governance)
[ ] Community Impact (e.g., energy access, diaspora engagement)
[ ] Networking (e.g., connect with African leaders, global professionals)
[ ] Other (specify): [______________________________]
Specific Areas of Interest (select all that apply):
[ ] Energy Innovation (e.g., renewable energy portfolios, solar microgrids)
[ ] Policy Advocacy (e.g., energy equity frameworks, AU Agenda 2063)
[ ] Interstellar Governance (e.g., space policy, tech for space)
[ ] Project Portfolio Management (PPM, prioritization, governance)
[ ] ESG and Sustainability (e.g., CO2 reduction, green reporting)
[ ] Agile Project Management [ ] Technology Integration (e.g., AI in energy)
[ ] Other (specify): [______________________________]
Statement of Interest (max 250 words, describe why you want to join VORTEX-PMC+™ and how it aligns with your career or community goals)*:
[Text Box: ___________________________________________________________]
Section 5: Financial and Scholarship Information
Payment Preference:
[ ] Full Payment ($2,000–$5,000, depending on level)
[ ] Payment Plan (contact training@aussaresearch.org for options)
[ ] Scholarship Application (complete below)
Are You Applying for a Scholarship? (50% of trainees eligible, funded by AfDB, GCF grants):
[ ] Yes [ ] No
If Yes, provide justification (max 200 words, explain financial need and alignment with Aussa’s mission, e.g., diaspora engagement, energy access):
[Text Box: ___________________________________________________________]
Affiliation with Funders/Partners (optional, helps prioritize scholarship or sponsored seats):
[ ] AfDB [ ] World Bank [ ] GCF [ ] IRENA [ ] UCT [ ] MIT
[ ] Google Research Africa [ ] Strathmore [ ] Other (specify): [______________________________]
Section 6: Additional Information
Do You Require Any Accommodations? (e.g., language support, accessibility needs):
[ ] Yes [ ] No
If Yes, specify: [______________________________]
Would You Like to Join Aussa’s Membership Platform? ($300K revenue, access to research, events, diaspora networks):
[ ] Yes [ ] No
If Yes, provide preferred membership type: [ ] Individual ($500/year) [ ] Organization ($2,000/year)
Additional Comments or Questions:
[Text Box: ___________________________________________________________]
Section 7: Consent and Submission
Consent to Data Use: I understand that the information provided will be used by Aussa Research Institute to process my enrollment, assess eligibility, and tailor my training experience. Aussa adheres to GDPR and POPIA standards for data protection.
[ ] I consent to the collection and use of my data as described.
Authorization: I certify that the information provided is accurate and complete to the best of my knowledge.
Signature (type name if digital):
[]
Date:
[]
Submit Form:
[Button: Submit] (Online version)
OR
Email to training@aussaresearch.org or upload via www.aussaresearch.org.
Implementation Notes
Format: The form is designed as a fillable PDF (using Adobe Acrobat or similar) and an online form integrated into Aussa’s website via CRM software ($20K tech budget). Online submissions are processed through a secure cloud system ($50K tech budget, ISO 27001 compliant).
Data Collection: Captures personal, professional, and goal-oriented data to assess eligibility, tailor training (e.g., energy vs. interstellar focus), and prioritize scholarships (50% of trainees, $200K funded by AfDB, GCF). Diaspora and funder affiliations support community engagement ($300K memberships) and partnerships ($800K).
User Experience: Includes dropdowns, checkboxes, and text boxes for ease of use, with clear instructions and contact details for support. The form is multilingual (English, French, Amharic options) to ensure accessibility.
Processing: Managed by 1 Community Liaison ($80K) and 1 Project Coordinator ($80K), with CRM software tracking applications and generating reports for the training team (CRO, Research Lead). Ensures 100% response within 48 hours.
Funder and Partner Appeal: Collects affiliation data to align with funder priorities (AfDB, GCF for diaspora and energy access), supporting $3M grants and $800K partnerships. Scholarship justification ensures equitable access, appealing to IRENA and World Bank.
Revenue Impact: Supports $800K training revenue by streamlining enrollment for 500+ trainees (Associate: $400K, Practitioner: $450K, Strategist: $400K, Architect: $250K, Specialty: $300K), plus $620K from bespoke services.
Post-Submission Process
Confirmation: Applicants receive an automated email confirmation within 24 hours, with details on next steps (e.g., interview, payment instructions).
Review: Training team reviews applications within 7 days, prioritizing diaspora youth, African professionals, and funder/partner affiliates.
Interview (if needed): Virtual interview ($10K tech budget for Zoom) for Strategist, Architect, and scholarship applicants to assess fit and goals.
Enrollment: Accepted applicants receive an enrollment package (program details, payment link, schedule) and are invited to a virtual info session ($10K marketing budget).
Scholarship Decisions: Notified within 14 days, with 50% of trainees (250) receiving full or partial funding, ensuring equitable access.
This fillable intake form is designed to streamline enrollment, gather critical data, and enhance Aussa’s engagement with participants, funders, and partners. If you need a visual mockup, additional fields, or integration details (e.g., CRM setup, website embedding), or want to refine any aspect, please let me know!