Participant Nomination Form

Transcription

1 TRAINING PROGRAMME ON REGIONAL OCEAN GOVERNANCE FRAMEWORK, IMPLEMENTATION OF THE UNITED NATIONS CONVENTION ON THE LAW OF THE SEA (UNCLOS) AND ITS RELATED INSTRUMENTS IN THE SOUTHEAST ASIAN & THE INDIAN OCEAN Navyphirom Hotel, Royal Thai Navy Hua Hin, Prachuap Khiri Khan, THAILAND July 1-28, 2018 Participant Nomination Form To be completed by a senior official of the nominating Government department/national or regional organization. The Government/organization nominates as a candidate to attend and certifies that: (a) (b) (c) (d) all information supplied by the nominee in the attached form is complete and correct; the nominee has adequate knowledge, appropriately tested, of the English language; the absence of the nominee during his/her attendance at the course would not have any adverse effect on his/her status, seniority, salary, pension or similar rights; and, if selected, the applicant would conduct at least one seminar/workshop after the course to share the knowledge and skills gained from the training. On return from attendance at the course, it is proposed to employ the candidate as follows: Title of candidate s proposed post: Proposed duties and responsibilities: Name of nominator Signature of nominator Title of nominator Postal address Official seal: address

2 Application Instructions Photo The application form is to be completed in English by the candidate. Please type or write clearly using block capitals. Each question must be answered, as complete and detailed information is required for the most appropriate selection of candidates. If necessary, additional pages of the same size may be attached. A functioning address is imperative to ensure timely communication, and applications cannot be considered without one. 1. Title (Mr/Ms/Dr) Given Name(s) Family Name (Surname) 2. of Birth: Day Month Year 3. Office Postal Address Courier Address (include street name & no.) Home Postal Address 4. Contact numbers Country Area Number Hours code code Fax (please include hours of operation):.. Work telephone (please include working hours): Home and/or mobile telephone:. address (es):. 5. Name, address, telephone & fax numbers of person to be notified in case of emergency 6. Passport No. Country of Issue of Issue Expiry Do you have an additional passport? Yes / No (circle one) If Yes, state country of issue: 7. Languages (indicate level of proficiency in reading, writing and speaking) Mother Tongue (specify): English: Other(s) (specify): Read Write Speak Please describe your practical experience in spoken English (e.g. occasionally have conversations with visitors, use English regularly at work, attended English-language university) Have you ever taken a TOEFL/IELTS? Yes / No (circle one) If Yes, state the test name, score and date: Please note that telephone interviews may be conducted to assess the candidate s English capabilities.

3 8. Post-secondary Education and Training (Start with most recent and work backwards) Name of Institution s of Study Qualification/Degree & Subject (e.g. B.Sc. in Marine Biology) 9. Scholarship(s) you have previously held 10. IOI Training Programme(s) you have previously attended 11. Employment Record (i) Title of current/most recent position: Years of service (from - to): Name and postal address of employer/organization: Name and address of supervisor: Detailed description of your work: If selected, will you be returning to this position after the course? If No, please clarify: Yes / No (circle one) (ii) Title of previous position of most relevance: Years of service (from - to): Name and postal address of employer/organization: Name and address of supervisor: Detailed description of your work:

4 12. Membership in professional societies and activities in civil, public or international affairs of relevance 13. Relevant publications you have written (do not attach) 14. Organizations or funding agencies applied to for scholarships (attach copies of correspondence). Please note that IOI scholarships are intended for those who can demonstrate they have attempted to find external funding. 15. Detailed description of the practical use you will make of this training on your return home, in relation to the responsibilities you expect to assume and the conditions existing in your country in your field of work. Please also include a brief outline of how you would share the knowledge and skills gained during the programme through at least one seminar or workshop on your return, and who/how many people would benefit from this. (Use extra page if you require additional space.) 16. Proposed course of attendance July 1-28, Where/how did you hear about the IOI training programme? 18. I certify that my statements in answer to the foregoing questions are true, complete and correct to the best of my knowledge Signature of Candidate Contact Address: International Ocean Institute, Thailand Operational Center (IOI-Thailand) Plodprasop Building, 7 th Floor Department of Fisheries Kaset Klang, Chatuchak, Bangkok 10900, Thailand Tel: , ioi.thailand@hotmail.com All nominees should complete application form and return to IOI Thailand (ioi.thailand@hotmail.com) as soon as possible but no later than 10 May 2018 Successful applicants will be notified of their acceptance by 15 May 2018

5 Medical Report Instructions To be completed by a registered medical practitioner after thorough clinical and/or laboratory examination. The IOI reserves the right to require the candidate to undergo a further medical examination before his/her course participation. Name of Candidate of Birth Male/Female Is the person examined at present in good health and enjoying full working capacity? Is the person examined able, physically and mentally, to carry on intensive study abroad? Does the person examined have any infectious or other diseases (for example, tuberculosis, trachoma, malaria, AIDS) which could present risks for the candidate and/or his/her contacts during the course? If so, please provide details. Does the person examined have any conditions (including but not limited to pregnancy) or any allergies which might require treatment during the course? If so, please provide details. It is important to note that the medical insurance does NOT cover pre-existing conditions, and the participant would find medical care extremely expensive in Thailand. Name and Address of Examining Physician: Signature of Examining Physician