T}IATLAND INTERNANONAL DEVELOPMENT COOPERATION AGENCY 962 Krung Kasem Road, Bangkok 10100 Thailand
TeL 6622817633,6622818076 Fax 66 2281 6385, 2280 3Bg9 Email : tica@mfa.go.th Websirer *ar'\l,.nfa.go.rh
SCHOLARSIIIP APPLICATION FORM
FOR OFFICIAL USE ONLY
Important Instructions:
- This application fofm is composed offive parts and should be t)?ed or print€d clearly
- Pan 1 to pan 4 should be completed by the candidate and pan 5 by the government audrodty
- Each question must be answered clearly and completely. Detailed answers are r€quired in orde. to make the most appropriate arangements.
- Oflicial authority of the nominating Government lyill formaUy nominate and forward three copies of the certified applicatiotr forms to the TEAILAND INTERNATIONAL DEVELOPMENT COOPERATION AGENCY through the Royal Thai Ent assy in the nominating country. ' fbe ncminee is required to attach medical report or health status certification. - No consideration lyill be given to the late submissions or incomDlete
applications/documents.
(Please attach photo$aph here)
Title oiCourse:
Name of Academic Institution:
1. PERSONAL DATA
Title Iram y name/surnametas shofn in
passport) First name Sex
O Mr. O Mis. O Ms.
O Male
City and country ofbirth Nationality
Date ofbit'l
(DDA4M/YY) 6 -- |
Manrat ''6'
I Status Religion
F6ik-lFss (Pl"aii comPlete this sectrou as clear as possible, informarion will be used for tr"avel arraDgemenl)
Hor"e-drcss (Pte"s" complet€ this section as Dossible. infotnatio! will be used for ravel
clear as ar:ugemenLi
Fax
Area Code / Number)
Telephone No :
(Coutrhy CoddArea Coden'lun$e,
Itrternationrl Airport/City for deParture
Email address
Name and adalress ofperson to be Dotified in case olemergency :
T e l e p h o n € N o : . . . - . . . . . . . - . . . R e l a t i o n s h i p o f t h i s p e r s o n t o y o u : " - '
Languages READ WRITE SPEAI{
M o t h e r t o n g u e - . . . . . . . . Exellent I C@d I Fai.
English
English Profrciency Test (please attach)
! rorrr,
score...
I other (speciiy) ...,.I mlr
EDUCATION R.ECORD
Education Institution City / Country
;-l
ltended I ;-_-]
Dege€s, Diplomas and Crnificares
Majorfieldof study
Have you ever been trained in Thailand? lf yes, what courle, where and for how long?
For a candidaie fcr a degree course, please give a lisl ofreievant publications/researches tdo nor awlcn o€raNl
57
2. EMPLOYMENT RXCORD : 1t is important
to give complete
information.
For each
post yof have
occupied,
give details
ofyour duties
and responsibilities,
Present or most recent post :
Dates from to
Description of your work
including your persoml respotrs,ibilities Title ofyour post :
Name of organisation ;
T)?e of organisation :
Official ad&ess :
Previous post :
Dates ftom to
Description of your work,
including your personal responsibilities Title of your post I
Name oforganisation :
T)?e of organisation :
Oificial address :
Please continue on supplementary pages ifnecessary. 3, EXPECTATIONS
et.u bdon to lle
responsibilities you expect to assume and the conditioDs existing in your country in the field of you. training. (Please continue on supplementary pages ifnecessary)
I cenify thal, to the best ofmy knowledge,
(a) all information suppiied by the nominee is comptete and correct;
(b) the nominee has adequate loorvledge and expe.ience in relared fields and has adequate Enqlish proficieDcy for the puryose ofthe fellowship in Thailald.
On retum ftom the fellorvship, the rominee wilt b€ employed in the folowing position : Title ofpost
Duties and responsibiti€s
4. REFERINCES (please attach the ftcommerdation letteN Aom two persons acquainted with your
I certit that my statemenfs in answer to the foregoing questions are hue, complete and co[€ct to tle best of my knowledge and belief.
If accepted for a tlaining award, I undertake to
:-(a) carry out such instructions and abide by such conditions as may be stipulated by both goverlment aad the host goverft:ent iD rcspect ofthis coulse oftraining;
(b) follow the course of haining, and abide by the rules of tle University or other establishment in tvhich I undertake to hain:
(c) reiain from engaging in political activities, or any form of employment for profit or gain; (d) submit any progress reports which may be prescribed;
(e) retum to my home country promptly upon the completio! of my course of haiimg.
I also fully understand that if I am granted a fellowship awar4 it may be subsequenily withdra\rn if I fail ro
make adequate progress or for otler sufficieit cause deiermined by the host Government.
Signature of applicant :.
5, GOVERNMENT AUTHORISATION : To be complered by the nominating covemment or the agency ftom whom the Domination has been invited.
Page 4 of4 pages Official address:
Sigmture of responsible Govemnent ofiicial
Date
Attachment
MEDICAL R.EPORT
Name of Nominee Age : ...Sex :..-...
Countrv
?hysical Examination (To be fiIled in by physician) Height...ClDs. Weight
Vision Right... Lefi.
...,kgs.Blood Pressure... mm.Hg. Eyes...-. Withglasses
Pulse .-.-...,..-."/Inin. / Without glasses Check each item in appiopdate column
Items Normal Abnormal Additiolal Comments
ceneral Skin, Scalp Lymph nodes Eyes Ears : Otoscopic Exam NOSe
Pharynx
& tonsils
Teeth
Thyroid
gland
Lungs
Head
Abdomen
Liver
Spleen
Hernia
External
genitalia
Rectal
exam.
Vertebrae
LOCOmOIOTReflexes
Mental
health status
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
( \ ' no
LABORATORY EXAMINATIONS
Health Stalus Certilication
I confirm that I am physically and mentally fit and able to carry on an intensive training in Thailand, and that
I
i
(a)
I am tiee intbctious
diseases
(such
as tuberculosis,
leprosy,
syphilis
and
fila asis)
:
and
other
conditions
(such
as psychosis,
drug
addiction,
and chronic
alcoholism)
rrhich could
present
risks
for myselfas
well as others
duing my fellowship;
(b)
I have
no conditions
or defects
which
might
require
treatment
during
my
f€llowship.
(c) I am not in a state ofpregnancy.
Signatu Printed
re ofapplicant: name:
Daae:
