Registration Form Final

							                             NOMINEE DIRECTORS FOR
                CORPORATE EQUITY PANEL – REGISTRATION FORM (5 PAGES)


PLEASE TYPE IN OR TICK THE BOXES BELOW – FAILURE TO COMPLETE ALL SECTIONS
FULLY IS LIKELY TO RESULT IN THE AUTOMATIC REJECTION OF YOUR APPLICATION:

Date: ________________________

1.   Please tick box to confirm that you are applying in your capacity as an individual (as opposed to as
     an employee of a company) and that you understand that any contract which you may be awarded as
     a result of your being placed on the panel will be issued to you as a named individual.


2.   Name of individual (first name, then family name – please include title - e g. Mr or Ms):




3.   Nationality of individual:




4.   Full Address:




5.   Contact details:

      Landline telephone number (incl country code):   Mobile (incl country code):


      Fax (including country code):                    E-mail:


6.   Current position:




7.   Required minimum daily fee rate/currency:




CONTINUED….

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8.   Relevant expertise (tick boxes for each relevant expertise and indicate number of years of
     appropriate experience):


                                  Industry/sector                         # of years
                                                                          Experience
                   Natural resources (including oil, gas and
                   mining)

                   Energy sector – power generation,
                   distribution and renewables

                   Pharmaceuticals

                   Real estate

                   Insurance, pensions, leasing or mortgage
                   finance

                   Information communications technologies

                   Arable food production, food processing,
                   production of (non) alcoholic beverages,
                   FMCG, retail

                   Transportation and logistics

                   Infrastructure

                   Pulp, paper and packaging

                   Manufacturing (please state industry)

                   Banks

                   Equity funds




CONTINUED….
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                               Core competencies                         # of years
                                                                         experience
                   Senior Management positions such as CEO,
                   CFO or COO

                   Supervisory Board membership

                   Privatisation

                   Strategic planning

                   Listed companies

                   Financial planning

                   Accounting procedures (including IFRS)

                   Institutional restructuring

                   MIS

                   Internal audit

                   Policy dialogue

                   Staff training

                   Venture capital

                   IPOs

                   Familiarity with EBRD mandate


9.   Please give a short synopsis of individual’s experience in terms of Board committees (e.g. audit,
     corporate governance or remuneration). Please indicate if the individual has experience of acting
     as chair to any such committees:




CONTINUED….
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10.   Please give a short synopsis of individual’s main expertise:




11.   Country experience:

            Country             No. of        Country              No. of         Country             No.
                            assignments/                       assignments/                      assignments/
                              projects                           projects                          projects
                             completed/                         completed/                        completed/
                             underway                           underway                          underway
       Albania                             Kazakhstan                           Russian
                                                                                Federation

       Armenia                             Kyrgyz Republic                      Egypt, Jordan,
                                                                                Morocco or
       Azerbaijan                          Latvia
                                                                                Tunisia

       Belarus                             Lithuania                            Slovak
                                                                                Republic
       Bosnia and                          Moldova                              Tajikistan
       Herzegovina

       Bulgaria                            Mongolia                             Turkey
       Croatia                             Montenegro                           Turkmenistan
       Estonia                             Poland                               Ukraine
       FYR Macedonia                       Romania                              Uzbekistan
       Georgia                             Serbia
       Hungary                             Slovenia


12.   Language skills: (Mark 1 to 5 for competence, 5 being the highest)

       Language              Reading Competence         Spoken                Written Competence
                                                        Competence
       English


13.   Are you currently nominated or have you ever been nominated to any Board seats by EBRD? If
      so, please provide details




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CONTINUED….

14.   Have you ever worked as a permanent staff member at EBRD? Please answer ‘yes’ or ‘no’. If
      ‘yes’, please provide details of last role + dates of employment




15.   Any other information relevant to your application (e.g. other IFI experience):




END




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