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Course Title: Venue: Application Date:
DD
MM
YYYY
Please return the completed form to Training Services Unit via HYPERLINK "mailto:tsu@adpc.net" tsu@adpc.net.
1. FULL NAME ( to be used in the course certificate )2. TITLE First Name Middle Name Last Name
[ ] MR
[ ] MS
[ ] MRS
[ ] Others, specify_______( full as to appear on the course certificate )
3. NATIONALITY4. PASSPORT5. GENDER6. DATE OF BIRTH7. AGEPassport Number:
Passport Expiry: [ ] female
[ ] male[ dd.mm.yy ]
8. ORGANIZATION INFORMATION9. CONTACT INFO (Work)Position/Title: Tel:
Fax:
Mobile:
Email:
Organization Name: Organization Address:
Country:
10. HOME ADDRESS11. CONTACT INFO (Personal)
Tel:
Email:
12. EMERGENCY CONTACT INFORMATION13. FOOD PREFERENCE(name and address of person to contact in case of emergency)
[ ] Vegetarian
[ ] Non-vegetarian
[ ] Others, specify
Relationship: Tel:
14. ENGLISH LANGUAGE PROFICIENCY
Note: proficiency in English is essential
E Excellent; G Good; F Fair15. ARE YOU FAMILIAR WITH THE USE OF PERSONAL COMPUTER?READ
E G F
[ ] [ ] [ ]WRITE
E G F
[ ] [ ] [ ]SPEAK
E G F
[ ] [ ] [ ]
[ ] Yes [ ] No
16. EDUCATION Start with the most recent institution attended. Please use additional sheet when necessaryInstitution Years attended Major field of study Degree
17. EMPLOYMENTStart with the most recent institution employed. Please use additional sheet when necessaryPosition/Title Organization Period (from- to) Responsibilities
18. MEMBERSHIP TO PROFESSIONAL SOCIETIES*
19. GIVE A BRIEF DESCRIPTION OF YOUR PRESENT INVOLVEMENT IN DISASTER MANAGEMENT-RELATED RESPONSIBILITIES*
20. PREVIOUS INVOLVEMENT IN DISASTER MANAGEMENT- RELATED EXPERIENCE*
*Please use additional sheet when necessary
21. SPECIAL INTERESTS IN THE FIELD OF DISASTER MANAGEMENT*
22. PREVIOUS COURSE(s) ON DISASTER MANAGEMENT AND RELATED SUBJECTS ATTENDED*International (give name of course(s), duration and dates)
In your country (give name of course(s), duration and dates)
23. PREVIOUS ATTENDANCE AT INTERNATIONAL WORKSHOPS AND TRAINING COURSES*
24. DESCRIBE THE PRACTICAL USE YOU WILL MAKE OF THIS COURSE ON YOUR RETURN HOME IN RELATION TO THE RESPONSIBILITY YOU EXPECT TO ASSUME*
*Please use additional sheet when necessary
25. ARRANGEMENTS FOR MEDICAL CARE: Accepted participants will be responsible for any medical expenses they may incur while in Thailand, and should consider arranging insurance before joining the course; Course Organizers will not be responsible for any medical expenses during the training. Please indicate if you are in good health.[ ] Yes [ ] No
26. PAYMENT OF FEE IS SETTLED BY: [ ] My Employer Please specify: [ ] A Donor Agency Please specify: [ ] Self-supportNote: If you are sponsored by your employer or donor agency, please attach recommendation letter from your sponsoring organization informing proposed arrangements for payment of fees.
27. MODE OF PAYMENT:
[ ] Bank transfer (*see ADPC bank details below) Fees are expected to be transferred to ADPC at least one month in advance.Account Name
Asian Disaster Preparedness Center (ADPC)
Account Number:
029-1-11600-0
Bank Address:
Kasikorn Bank, Sanampao Branch 1019/18 Phaholyotin road, Samsen Nai Phayathai, Bangkok, Thailand
Swift code:
KASITHBK, Thailand
Note: Please include participants name in the Originator to Beneficiary Information (OBI) section of the wire transfer form. Personal cheque and credit card are not acceptable.
28. ACCESS TO COURSE INFORMATION
How did you hear about the course?
[ ] ADPC website [ ] FACEBOOK [ ] Twitter [ ] Email [ ] Colleagues
[ ] Other website (please specify) __________________________________________
[ ] Conference/Workshop (please specify) ___________________________________
[ ] Other (please specify) ________________________________________________ Do you have any suggestions on how the course information might be more widely disseminated?
29. DECLARATION
I certify that the above statements are true and accurate to the best of my knowledge. If selected, I undertake to:
Fully attend all scheduled study activities
Refrain from political, commercial or any activities other than those covered by my study program.
Submit reports in accordance with the arrangements made by my employer or sponsoring agency.
Return to my home country at the end of the fellowship.
Be fully responsible for any medical expenses while undergoing training.
SIGNATURE OF APPLICANTDATE
PAGE
Safer communities and sustainable development through disaster risk reduction
Page PAGE 1 of NUMPAGES 4
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