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2019 Application Form Participants - Training Workshop on Maintenance of Infrastructure for Developing Countries, 22 - 25 July 2019, Kuala Lumpur, Malaysia
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Full Name (as in Passport)
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Designation
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Prof.
Dr.
Mr.
Mrs.
Ms.
Gender
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Male
Female
Nationality
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Passport Number
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Date of Birth
MM
/
DD
/
YYYY
Organization
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Applicant's Office Address
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Country
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Office Phone Number
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Office Fax Number
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Mobile Number
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Official E-Mail
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Personal E-Mail
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Person to be contacted in case of emergency (Name, Address and Phone)
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Education - Name of Institution
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Major field of study / Degree
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Year of study
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Other Degrees
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Employment Record - Current Post / Title of Post
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Duration of service
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Current monthly salary (US Dollar)
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Name of immediate supervisor and title of post
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E-Mail of immediate supervisor
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Type of organization
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Government
Semi-Government
Private
NGO
Others
Total number of employees in organization
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Description of your current work including your responsibility (100 words)
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Reasons for applying (100 words)
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Have you previously participated in any ISTIC programme?
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YES
NO
If yes (Name of programme and date)
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English Language Proficiency - Listening
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Excellent
Good
Fair
English Language Proficiency - Speaking
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Excellent
Good
Fair
English Language Proficiency - Writing
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Excellent
Good
Fair
English Language Proficiency - Reading
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Excellent
Good
Fair
Name of Head of Organization
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Address of Organization
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Head of Organization - Phone Number
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Head of Organization - Fax Number
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Head of Organization - E-Mail
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Declaration - Have you ever been convicted by a Court of Law of any country?
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YES
NO
If Yes, Please give brief details
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I (applicant) certify that my statements in answer to the foregoing question are true, complete and correct to the best of my knowledge and belief.
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Agreed
Not Agreed
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