Version 071011 Application Form for the jica training and Dialogue Program icon

Version 071011 Application Form for the jica training and Dialogue Program



НазваниеVersion 071011 Application Form for the jica training and Dialogue Program
Дата конвертации25.06.2013
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Version 071011

Application Form for the JICA Training and Dialogue Program

OFFICIAL APPLICATION

(to be confirmed and signed by the head of the relevant department / division of the applying organization)


1. Title: (Please write down as shown in the General Information)

Название курса на английском

2. Number: (Пожалуйста, впишите код, указанный в Общей информации)

J

1




-

















3. Country Name:

Republic of Kazakhstan


^ 4. Name of Applying Organization:

Название направляющей организации


5. Name of the Nominee(s):

1) имя и фамилия кандидата

3)

2)

4)


Our organization hereby applies for the training and dialogue program of the Japan International Cooperation Agency and proposes to dispatch qualified nominees to participate in the programs.

Date:

дата

Signature:

Подпись

Name:

Имя и фамилия руководителя

Designation / Position

Должность руководителя организации

Official Stamp

Гербовая печать

Department / Division

Название возглавляемого подразделения

Office Address and

Contact Information

Address: Адрес

Telephone:

Fax:

E-mail:







Подтверждение курирующей организации

^ Confirmation by the organization in charge (if necessary)

I have examined the documents in this form and found them true. Accordingly I agree to nominate this person(s) on behalf of our government.

Date:

дата

Signature:

Подпись

Name:

Имя и фамилия курирующего руководителя

Official Stamp Гербовая печать

Designation / Position

Должность руководителя курирующей организации

Department / Division

Название возглавляемого подразделения




Part A: Information on the Applying Organization

(to be confirmed by the head of the department / division)


^ 1. Profile of Organization


1) Name of Organization:

Название направляющей организации


^ 2) The mission of the Organization and the Department / Division:


Перечислить задачи Организации/Министерства и Департамента






^ 2. Purpose of Application


1) Current Issues: Describe the reasons for your organization claiming the need to participate in the training and dialogue program, with reference to issues or problems to be addressed.


Указать причины, по которым Организации/Министерству необходимо участие в тренинге, а также требующие решения проблемы.




^ 2) Objective: Describe what your organization intends to achieve by participating in the training and dialogue program.


Каких результатов намерено достичь Министерство посредством участия в тренинге




^ 3) Future Plan of Actions: Describe how your organization shall make use of the expected achievements, in addressing the said issues or problems.


Указать, как будут использованы Организацией/Министерством достигнутые результаты для решения вышеуказанных проблем.




4) Selection of the Nominee: Describe the reason(s) the nominee has been selected for the said purpose, referring to the following view points; 1) Course requirement, 2) Capacity /Position, 3) Plans for the candidate after the training and dialogue program, 4) Plan of organization and 5) Others.


Перечислить причины, по которым предлагается данная кандидатура






^ Part B: Information about the Nominee

(to be completed by the Nominee)

NOTE>>>The applicants for Group and Region Focused Training Program are required to fill in “Every Item”. As for the applications for Country Focused Training Program including Counterpart Training Program and some specified International Dialogue Programs, it is required to fill in the designated “required” items as is shown below.


1
Attach the nominee’s photograph (taken within the last three months) here

Size: 4x6
(Attach to the documents to be submitted.)
. Title:
(Please write down as shown in the General Information) (required)

Название курса на английском

2. Number: (Please write down as shown in the General Information) (required)

J

1




-

















^ 3. Information about the Nominee(nos. 1-9 are all required)

1) Name of Nominee (as in the passport)

Family Name

и

м

я




















































^ First Name

ф

а

м

и

л

и

я








































^ Middle Name

о

т

ч

е

с

т

в

о





































^ 2) Nationality

(as shown in the passport)

Kazakhstan

5) Date of Birth (please write out the month in English as in “April”)

3) Sex

( ) Male

( ) Female

Date

Month

Year

Age

^ 4) Religion

















6) Present Position and Current Duties

Organization

Название организации

Department / Division

Название Департамента/Управления

Present Position

Занимаемая должность

Date of employment by the present organization

Дата приёма на работу

Date

Month

Year

Date of assignment to the present position

Дата назначения на должность

Date

Month

Year




















^ 7) Type of Organization тип организации


( ) National Governmental

( ) Local Governmental

( ) Public Enterprise

( ) Private (profit)

( ) NGO/Private (Non-profit)

( ) University

( ) Other ( )


^ 8) Outline of duties: Describe your current duties


Перечислите свои должностные обязанности





^ 9) Contact Information Контактная информация

Office

Рабочий

Address:

TEL:

Mobile (Cell Phone):

FAX:

E-mail:

Home

Домашний

Address:

TEL:

Mobile (Cell Phone):

FAX:

E-mail:

Contact person in emergency

Контактное лицо на непредвиденный случай

Name:

Relationship to you: какое имеет к вам отношение

Address:

TEL:

Mobile (Cell Phone):

FAX:

E-mail:


10) Others (if necessary)

Другое



^ 4. Career Record

1) Job Record (After graduation) Опыт работы

Organization

City/

Country

Period

Position or Title

Brief Job Description

From

Month/Year

To

Month/Year

Название организации

Город/страна







Занимаемая должность

Краткое описание выполняемой работы






































^ 2) Educational Record (Higher Education)(required) Образование

Institution

City/

Country

Period

Degree obtained

Major

From

Month/Year

To

Month/Year

Название ВУЗа

Город/страна







Полученная степень

Специальность






































^ 3) Training or Study in Foreign Countries; please write your past visits to Japan specifically as much as possible, if any. Обучение за рубежом

Institution

City/

Country

Period

Field of Study / Program Title

From

Month/Year

To

Month/Year

Название организации, проводившей тренинг

Город/страна







Тема обучения/название семинара
































^ 5. Language Proficiency (required) Владение рабочим языком курса

1) Language to be used in the program (as in GI)




Listening

( ) Excellent

( ) Good

( ) Fair

( ) Poor

Speaking

( ) Excellent

( ) Good

( ) Fair

( ) Poor

Reading

( ) Excellent

( ) Good

( ) Fair

( ) Poor

Writing

( ) Excellent

( ) Good

( ) Fair

( ) Poor

Certificate (Examples: TOEFL, TOEIC)

Сертификат, подтверждающий уровень владения языком

2) Mother Tongue

Родной язык

3)Other languages ( другой язык)

( ) Excellent

( ) Good

( ) Fair

( ) Poor


Excellent: Refined fluency skills and topic-controlled discussions, debates & presentations. Formulates strategies to deal with various essay types, including narrative, comparison, cause-effect & argumentative essays.

Good: Conversational accuracy & fluency in a wide range of situations: discussions, short presentations & interviews.

Compound complex sentences. Extended essay formation.

Fair: Broader range of language related to expressing opinions, giving advice, making suggestions. Limited compound and complex sentences & expanded paragraph formation.

Poor: Simple conversation level, such as self-introduction, brief question & answer using the present and past tenses.


^ 6. Expectation on the applied training and dialogue program


1) Personal Goal: Describe what you intend to achieve in the applied training and dialogue program in relation to the organizational purpose described in Part A-2.

Указать подробно, какова ваша личная цель участия в тренинге, что вы намерены достигнуть в связи с задачами, стоящими перед организацией/Министерством



2) Relevant Experience: Describe your previous vocational experiences which are highly relevant in the themes of the applied training and dialogue program. (required)


Опишите ваш профессиональный опыт, соответствующий теме тренинга




^ 3) Area of Interest: Describe your subject of particular interest with reference to the contents of the applied training and dialogue program. (required)


Ваша сфера интересов: укажите интересующие вас темы, которые имеют отношение к содержанию тренинга



*7. Declaration (to be signed by the Nominee) (required)

I certify that the statements I made in this form are true and correct to the best of my knowledge.

If accepted for the program, I agree:

  1. not to bring or invite any member of my family (except for the program whose period is one year or more),

  2. to carry out such instructions and abide by such conditions as may be stipulated by both the nominating government and the Japanese Government regarding the program,

  3. to follow the program, and abide by the rules of the institution or establishment that implements the program,

  4. to refrain from engaging in political activity or any form of employment for profit or gain,

  5. to return to my home country at the end of the activities in Japan on the designated flight schedule arranged by JICA,

  6. to discontinue the program if JICA and the applying organization agree on any reason for such discontinuation.

  7. to consent to waive exercise of my copyright holder’s rights for documents or products that are produced during the course of the project, against duplication and/or translation by JICA, as long as they are used for the purposes of the program.




Date:

Signature: подпись

Print Name: Фамилия и имя



^ MEDICAL HISTORY AND EXAMINATION
1. Present Status

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

    ( ) No

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

  2. Are you pregnant?

    ( ) No

    ( ) Yes ( months )

  3. Are you allergic to any medication or food?

    ( ) No

    ( ) Yes >>>

    ( ) Medication

    ( ) Food

    ( ) Other:

  4. Please indicate any needs arising from disabilities that might necessitate additional support or facilities.

( )

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


^ 2. Medical History

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

    Past:

    (v ) No

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

    Present:

    ( v) No

    ( ) Yes>>Present Condition ( )

  2. Have you ever been a patient in a mental hospital or been treated by a psychiatrist?

    Past:

    ( v ) No

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

    Present:

    ( v) No

    ( ) Yes>>Present Condition ( )

  3. High blood pressure

    Past:

    (v ) No

    ( ) Yes

    Present:

    ( v ) No

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

  4. Diabetes (sugar in the urine)

    Past:

    ( v ) No

    ( ) Yes

    Present:

    ( v ) No

    ( ) Yes>>Present Condition ( )

    Are you taking any medicine or insulin?

    ( ) No

    ( ) Yes

  5. 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’) Has this disease been cured?

( ) Yes

( ) No (Specify name of illness)

Present Condition: ( )

^ 3. Other: Any restrictions on food and behavior due to health or religious reasons?

Ограничения в еде по состоянию здоровья или религиозным убеждениям

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

I understand and accept that medical conditions resulting from an undisclosed pre-existing condition may not be financially compensated by JICA and may result in termination of the program.

Date:

Signature: подпись

Print Name: Фамилия и имя





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