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TIIAILAND INTERNATIONAL DEVELOPMENT COOPERATION AGENCY 962 Krung Kasem Road, Bangkok 10100 Thailand
Tet.66 22817633,66 22818076 Fax 66 2281 6385, 2280 3889 Email: tica@mfa.go.th Website:www.mfa.go.th
SCIIOLARSHIP APPLICATION FORM
FOR OFFICIAL USE ONLY Reference N o . . . , . . . . Received:
Checked:
Important Instrucfions:
- This application form is composed of five parts and should be typed or printed cleaf,ly
- Part I to part 4 should be completed by the candidate and part 5 by the
government authority
- Each question must be answered clearly and completely. Detailed aDswers are
required in order to make the most appropriate arangements.
- Oltrcial authority of tho nominating Government will formally nominate and forward three copies of the certitrod application forms to the
TIIAILAND INTERNATIONAL DEVEIOPMENT COOPERATION
AGENCY through the Royal Thai Embassy in the nominating country. - The nominee is required to attach medical report or healti status certification. - No consideration will be given to the late submissions or incomplcte
applicationVdocuments.
(Please attach
photograph here)
Title of Course:
Nrme of Academlc Institution:
1. PERSONALDATA
Tltle Famlly name /Surname(as shown lnpassport) Flrst name Sex
o Mr. o Mrs.
o Ms.
o Male o Female
City and counEy of birth Nationality
Date ot bfth
(DDA4M/rY) Age
Marital
Stahls Religion
Work address (Please complete this section as clear as possible, infonnation will be used for travel arrangement)
Home address (Please cornplete this section as clear as possible, infonnation will be used for travel
arrangement)
Fax No : (Country Code / Area Code / Number)
Telephone No : Telephone No :
(Country Code/Area CodeNumber)
Internadonel AirporUCity for departure
E * ^ i l - . { , { . - . d
Languages : REAI) WRITE SPEAI(
Mother longue : . . . Excellert Good Fair Excellent Good Fair Excellent Good Fair
English
English Proficiency Test (please atfach)
D rorrr.
score
...
[ Other (specify)I mr,r
score
...
EDUCATION RECORI)
Education Instinrtion City / Coutry Years Attended Degrees, Diplonas and Certificates
Major field of sudy
From To
Have you ever been trained in Thailand? Ifyes, what coune, $'here and for how long?
F"r
" .-did"tr f* a degtee coutse, please give a list ofrelevant publicationVresearches
(do not attach details)
2. EMPLOYMENT RECORD : It is important to give complete information. For each post you have
occupied, give details ofyour duties and respotrsibilities.
Pfesent or most recent post :
Dates from to
Description of your wotk,
including your personal responsibilities
Title ofyour post :
Name of organisation :
Type of organisation :
Official address :
Previous post :
Dates from to
Ilescriptron of your work,
including your personal responsibilities
Title ofyour post :
Name of organisation :
Type of organisation :
Official address :
Please continue on supplementary poges ifnecessary.
3.DOECTATIONS
Please describe the practical use you will make of rhis training/study on your return home in relation to the
r€sponsibilities you expect to ltssume and the conditions existing in your county in the field ofyour training.
(Please continue on supplementary pages if necessary)
4. REFTRENCES (please attach tle recommendation letteF from two persons acquainted with your
academic and professional experiences.)
I certifr that my statements in answer to the foregoing questions are true, complete atrd conect to the best of
my knowledge and belief.
If accepted for a training award, I undertake to :
-(a) carry out such instructions and abide by such conditions as may be stipulated by both the nominating govemment and the host govemment in respect of this course of training;
(b) follow the coune of training, and abide by the rules of the University or other institutions or establishment in which I undertake to train;
(c) refrain 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 completion of my course of training
I also fully understand that if I am granted a fellowship award, it may be subsequently withdrawn
ifl fail to make adequate progress or for other sufficient cause deterrnined by the host Govemment.
T)ete '
5. GOVERNMENT AUTHORISATION : To be completed by the nominating Govemment orthe
agency from whom the nomination has been invited.
I certi& thal to the best ofmy knowledge,
(a) all information supplied by the nominee is cornplete and correct ;
(b) the nominee has adequate knoveledge and experience in related fields and has adequate English proficiency for the purpose of the fellowship in Thailand.
On rehrm from the fellowship, the nominee will be employed in the following position :
Tifla nfnncl
n-+:-. ^n,{ .."*-"if ilitiac
Officialsamp:
frrlpaicotinn .
Attachment
MEDICALREPORT
Nona nf Nnrninpp Age : ...Sex : ...
Pulse ...,.../min.
/ Without glasses Physical Examination (To be filled in by physician)
Height... Cms. Weight...tgs. Blood Pressure ... mm.Hg.
Vision Right . . .. Left...,....
Check each item in appropriate column
Eyes ... With glasses
ltems
General
Skin, Scalp
Lymph nodes
Eyes
Ears :
Otoscopic Exam
Nose
Pharynx & tonsils
Teeth
Thyroid gland
Lungs
Heart
Abdomen
Liver
Spleen
Hernia
External genitalia
Rectal exam.
Vertebrae
Locomotor
Reflexes
Mental health stahrs
Normal
o
o
o
o
o
Abnormal
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Additional Comments
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
LABORATORY EXAMINATIONS
Blood group Blood film for malaria ... . ... Hb " gm%
WBC ... ... CellVcumm.
Differential PMN...o/o Lymp 7o Mono o/o Eos o/o
Baso ... Yo Band... Yo Blast """ " %
Micro: WBC . . /HPF., RBC . ... . "/HPF', Epethelial /HPF'
a4^^r ^:^-:--+:^- f^- --6di+a ,{, rlt'o
,1L--+ L D.r' rA^^rt
T T.:-(Jruv
PrwSu(uwJ
Is the nominee able physically and mentally to carry on intensive study away from home?
diseases, filariasis etc.) and other conditions (such as psychosis and drug addiction) which could present risks
for anyone during the fellowship period?
Full name and address of
Examining physician (printed)
Telephone:
(pdnted)
e m a i l : .. . . .
