PHEMAP-1 | OVERVIEW | MODULES | APPLICATION FORM | VENUE | CONTACT

A Programme of Courses in
Public Health and Emergency Management in Asia and the Pacific (PHEMAP)


PHEMAP Online Application Form
NOTE: Please do not leave any fields blank. Use "N/A" for fields that are not applicable to you.

Family Name: 


First Name:


Middle Initial:


Sex
Male Female

Marital Status:

Specify:
Nickname:


Nationality:


Age:
  
Date of Birth :
Home Address:
   Home Phone:
  
Office Address:


Phone Number:

Fax Number:


Telex Number:

 

E-mail:

Cable Address:

  
Name and Address of Person
to notify in case of emergency
  
Relationship:

Phone Number:

  
English Language Proficiency
(Please click where appropriate)
    
Read
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Fair		   Write
Excellent
Good
Fair		   Speak
Excellent
Good
Fair
Are you familiar with the use of Personal Computer (PC)?
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Education (Start with the last institution attended)
    
Institution



  Year Attended



   Major Field Study



   Degree
Employment        
Present Title

Previous Title/s


  Organization

Organization


  Period: from - to

Period: from - to


  Responsibilities

Responsibilities


Membership of Professional Societies
Give a brief description of your present involvement
in public health snd emergency management
Previous public health and emergency management experience
Special interest in the field of public health and emergency management
Previous Course(s) on Public Health Emergency Management and related subjuect attended

(A) International (give name of course(s), duration and dates)


(B) In your country
Previous international travel an training courses, seminars, study tours, etc
Describe the practical use you will make of this course on your return home
in relation to the responsibilities you expect to assume.

Are you in good heath? (Accepted participants will be responsible
for any medical expenses they may incur while in AIT and should
consider arranging insurance before joining).

Yes No
DECLARATION

 I certify the above statement 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 the study program.

 (d) Submit reports in accordance with the arrangements made by my employer or sponsoring agency.

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

 (f) Be fully responsible for any medical expenses while undergoing training.