(ii) Date of Course (DD/MM/YY) :

(iii) How did you hear about the course? :  

2.  Information about the Applicant

(i)  Name :  choose prefix here Mr. Ms. Mrs.

Last Name     :

First Name     :

Middle Initial   :

Please also provide your nickname  :

(ii)  Nationality   :   

(iii)  Sex :   choose here Male Female

(iv)  Date of Birth (DD/ MM/ YY) :

(v) Office Address (please provide complete postal address) :

(vi)  Home Address :

 Telephone    :  

(vii)  Please provide here name and address of person to notify in case of emergency

(v) Languages:

3.  Education - institution, year attended, major field of study, degree (start with last institution attended):

4. Employment - appointment, organisation, period of duty, responsibilities (start with the present appointment):

5. Membership of Professional Bodies:

6. Give a brief description of your disaster-related responsibilities:

7. Previous disaster-related experience:

8. Special interests in the disaster field:

9. Describe the practical use you will make of this course on your return home in relation of the responsibilities you expect to assume.

10.  Are you in good health?   choose here Yes No

(Selected candidates will be responsible for any medical expenses they may incur while in AIT and should consider arranging insurance before joining)

11. Name and address of Sponsoring Organization:.

12.  Mode of Payment   choose here Cash-during RegistrationCheque payable to ADPC/AITBank Transfer

13. Declaration:

I certify that the above statements are true and complete to the best of my knowledge.  If selected, I undertake to:

a) Conduct myself at all times in a manner compatible with my status as the holder of a fellowship.

b) Spend all my time during the period of fellowship in the study program.

c) Refrain from political, commercial or any activities other than those covered by my study program.

d) Return to my home country at the end of fellowship.