Application form for koica training participants icon

Application form for koica training participants



НазваниеApplication form for koica training participants
Дата конвертации25.06.2013
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APPLICATION FORM FOR KOICA TRAINING PARTICIPANTS

(photo)






Korea International Cooperation Agency

HQ & ICC: 418 Daewang Pangyo-ro, Sujeong-gu, Seongnam-si, Gyeonggi-do, Korea

Tel: 82-31-777-2600  Fax: 82-31-777-2603 E-mail: training@koica.go.kr, http://www.koica.go.kr


^ . TITLE OF COURSE

 

. PERSONAL DATA

Name(passport)

First

 

Middle

 

Last(Sur)

 

^ Date of Birth

Month

 

Day

 

Year

 

Sex

□M    □F

Marital Status

 

Nationality

 

Religion

 

^ Passport Number

 

Airport of Departure

 

Home Address

 

Tel. No.

     -  -    

Country code    area code      number 

Fax No.

      -  -     

country code    area code      number 

Mobile No.

 

E-mail

 

Emergency Contact

Name

 

Tel. No.

 

. EMPLOYMENT

^ Present Position




Department




Name of organization

 

Address

 

Tel. No.

     -  -    

country code    area code      number 

Fax No.

      -  -     

country code     area code      number  

Type of Organization

□Governmental/Public □Private □International □Other

^ Term of Employment

from            to present

Describe your present duties

 


. OTHERS

^ 1. Describe any themes, topics and places of interest you would like to see in this training course.




2. Any restrictions on food and/or behavior due to health or religious reasons?

□Yes >> □Beef □Pork □Fish □Others(        )/ □No

^ 3. Are you allergic to any medication or food?

□Yes (                             )/  □No

. CAREER

^ Career over the past 5 years:

Name of Organization

From

To

Position/ Responsibilities

month/year

month/year

 

     /

     /

 

 

     /

     /

 

 

     /

     /

 

^ Educational background

Name of Institution

From

To

Field of Study and Degree

month/year

month/year

 

     /

     /

 

 

     /

     /

 

 

     /

     /

 

^ Former training experiences in Korea (KOICA) or other countries: □Yes    □No 

Name of Institution

From

To

Field of Study and Degree

month/year

month/year




/

/







/

/







/

/







^ . LANGUAGE PROFICIENCY


English:


 

Excellent

Good

Fair

Poor

Remarks

Listening

 

 

 

 

 

Speaking

 

 

 

 

 

Writing

 

 

 

 

 

Reading

 

 

 

 

 

 

^ Native Language :

Other Languages :                                                 


In case you speak English as a foreign language, it is required for you to certify your English proficiency. Please indicate your English Proficiency Test scores: 


^ TOEFL:                □ TOEIC:                  □Others:              

(IBT, CBT, PBT)  score                           score                             score


^ . MEDICAL REPORT 1 (to be completed by an authorized physician)

Name of Applicant:                     

Age:     

Sex:    

Height:         cm

Weight:           kg

 ^ Blood Type:

 Blood Pressure:        /          mmHg

 EKG

Normal     □Abnormal

 

 Chest PA

Normal     □Abnormal

 

 Urinalysis

Normal     □Abnormal

 

 Diabetes

Positive     □Negative

 

 Hepatitis B

Positive     □Negative

 

 Hepatitis C

Positive     □Negative

 

 Syphilis

Positive     □Negative

 

 AIDS

Positive     □Negative

 

 ^ Infectious disease

Yes         □No

 

 Endemic disease

Yes        □No

 

 Pregnancy test

Positive     □Negative

 



^ 1. If the applicant has a history of illnesses or disorders during the past 5 years, please describe the treatment and present status.


                                                                 


                                                                                


 

2. What opinions do you have about the overall health condition of the applicant in regards to him/her carrying out an intensive training course away from his/her home?


                                      


                                                                                


^ Name of Clinic:                            


Address of Clinic:                   


Name of Physician:                                


 

Date:                           Signature of Physician:                     



. MEDICAL REPORT 2 (to be completed by an applicant)

^ 1. Present Status


(a) Do you currently use any drugs for the treatment of a medical condition? (Give name & dosage.)

(  ) No

(  ) Yes >> Name of Medication (                      ), Quantity (             )


(b) Are you pregnant?(Female only)

(  ) No(  ),  Yes (                              months )


(C) Please indicate any needs arising from disabilities that might necessitate additional support or facilities.

(                                                                                  )


Note: A disability does not lead to dismissal or exclusion from the program. However, upon the situation, you may be directly inquired by the KOICA official in charge for a more detailed account of your condition.


^ 2. Medical History


(a) Have you had any significant or serious illnesses? (If hospitalized, give place & dates.)

Past:

(  ) No

(  ) Yes>>Name of illness (                ), Place & dates (             )

Present:

(  ) No

(  ) Yes>>Present Condition (                                            )


(b) Have you ever been a patient in a mental hospital or have been treated by a psychiatrist?

Past:

(  ) No

(  ) Yes>>Name of illness (           ), Place & dates (            )

Present:

(  ) No

(  ) Yes>>Present Condition (                                           )


(c) High blood pressure

Past:

(  ) No

(  ) Yes

Present:

(  ) No

(  ) Yes>>Present Condition (         ) mm/Hg to (           ) mm/Hg


(d) Diabetes (sugar in the urine)

Past:

(  ) No

(  ) Yes

Present:

(  ) No

( ) Yes>>Present Condition (                                              )

Present:

(  ) No

Are you taking any medicine or insulin?   

(  ) No

(  ) Yes


(e-1) Past History: What illness(es) have you had previously?

(  ) Stomach and Intestinal Disorder

(  ) Liver Disease

(  ) Heart Disease

(  ) Kidney Disease

(  ) Tuberculosis

(  ) Asthma

(  ) Thyroid Problem

 

(  ) Infectious Disease >>> Specify name of illness (                                               )

(  ) Other >>> Specify (                                                                      )


(e-2) Has this disease been cured?

(  ) Yes

(  ) No (Specify name of illness) :

(  ) Yes

Present Condition: (                                                                 )


I certify that I have read the above instructions and answered all questions truthfully and completely to the best of my knowledge.


Date:                 Signature of Applicant: _____________

^ . APPLICANT'S RESPONSIBILITIES

If accepted as a participant, I agree:

 

  1) to participate in the training course to the best of my ability and abide by the rules of the training institute, university, or college in which I undertake training;

  ^ 2) to refrain from engaging in political activity or any form of employment for profit or gain;

  3) to return to my home country upon completion of my training course and to resume work in my country;

  4) not to extend the length of my training or my stay for personal conveniences;

  5) not to bring any family members (dependents) to Korea or country of training;

  ^ 6) to accept that KOICA is not liable for any damage or loss of my personal property;

  7) to accept that KOICA will not assume any responsibility for illnesses, injuries, or death arising from extracurricular activities, willful misconduct, or undisclosed pre-existing medical conditions; and

  ^ 8) to carry out such instructions and abide by such conditions as may be stipulated by KOICA in regards to the training course; and

  9) to allow KOICA to collect information about me and to pass that information onto other relevant parties if necessary

 

     ^ I fully understand that my status as a participant may be terminated if I fail to make satisfactory progress or for any other reason determined by KOICA.


 

     Applicant's Name:                        Signature:                    


^ . OFFICIAL NOMINATION

 

 The Government of                                    officially nominates

                            (Name of Country)

                               for participation in                            

   (Full Name of Applicant)                                    (Name of Training Course)

 

                                                                                   

 

as organized by the Korean Government(KOICA), and certifies that:


^ 1) all information supplied by the applicant is complete and correct;

  2) the applicant has an adequate knowledge of and/ or expertise in the training field; and

  3) the applicant has a sufficient proficiency of spoken and written English to enable him/her to undergo the training course.


Name of Organization:                   

 Position/Title:                                                                      

 Name of Authorized Official:                                                        

 Date:                           Signature:                          





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