Beasiswa S2 2009 Thailand Application form
T}IATLAND INTERNANONAL DEVELOPMENTCOOPERATIONAGENCY
962Krung KasemRoad,Bangkok10100Thailand
TeL 6622817633,6622818076
Fax66 22816385,2280 3Bg9
Email: tica@mfa.go.thWebsirer
*ar'\l,.nfa.go.rh
FOROFFICIAL
USEONLY
SCHOLARSIIIP APPLICATION FORM
Important Instructions:
- This applicationfofm is composedoffive partsand shouldbe t)?ed print€d
or
clearly
- Pan 1 to pan 4 should be completedby the candidateand pan 5 by the
governmentaudrodty
- Each questionmust be answeredclearly and completely. Detailed answersare
r€quiredin orde. to makethe mostappropriatearangements.
- Oflicial authority of the nominatingGovernmentlyill formaUy
nominate
and forward three copies of the certified applicatiotr forms to the
TEAILAND INTERNATIONAL DEVELOPMENT COOPERATION
AGENCY through the RoyalThai Ent assyin the nominatingcountry.
' fbe ncmineeis requiredto attachmedicalreport or healthstatuscertification.
- No considerationlyill be given to the late submissionsor incomDlete
applications/documents.
(Pleaseattach
photo$aph here)
Title oiCourse:
Nameof AcademicInstitution:
1. PERSONALDATA
Title
Iram y name/surnametasshofn in
passport)
First name
Sex
O Mr.
O Mis.
O Ms.
City andcountryofbirth
O Male
Date ofbit'l
(DDA4M/YY)
Nationality
6 -''6'
|
I
Manrat
Status
Religion
PageI of4 pages
56
Hor"e-drcss (Pte"s" complet€this section as clear as
F6ik-lFss (Pl"aii comPletethis sectrouasclearas
possible,informarionwill be usedfor tr"avelarraDgemenl) Dossible.infotnatio! will be usedfor ravel
ar:ugemenLi
TelephoneNo :
(Coutrhy CoddArea Coden'lun$e,
Fax
AreaCode/ Number)
Itrternationrl Airport/City for deParture
Email address
Name and adalressofperson to be Dotified in caseolemergency :
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 :'
WRITE
READ
Languages
Mothertongue-...... .. ........
Exellent I
C@d
I
SPEAI{
Fai.
English
English Profrciency Test (pleaseattach)
! rorrr,
score........ I mlr
........,.
I other(speciiy)
EDUCATION R.ECORD
EducationInstitution
ltended
City / Country
;-l
;-_-]
I
Dege€s, Diplomas
and Crnificares
Majorfieldof
study
Have you ever been trained in Thailand?lf yes, what courle, whereand for how long?
tdo nor awlcn o€raNl
For a candidaiefcr a degreecourse,pleasegive a lisl ofreievant publications/researches
Page2 of4 pages
57
2. EMPLOYMENT RXCORD : 1tis importantto givecomplete
information.For eachpostyof have
givedetailsofyour dutiesandresponsibilities,
occupied,
Presentor most recentpost :
Datesfrom
Title ofyour post :
Descriptionof your work
including your persoml respotrs,ibilities
to
Name of organisation;
T)?e of organisation:
Official ad&ess:
Previouspost :
Datesftom
Title of your post I
Descriptionof your work,
including your personalresponsibilities
to
Nameoforganisation:
T)?e of organisation:
Oificial address:
Pleasecontinueon supplementarypagesifnecessary.
3, EXPECTATIONS
et.u
bdon to lle
you
responsibilities
expectto assumeandthe conditioDsexistingin your country in the field of you. training.
(Pleasecontinueon supplementarypagesifnecessary)
Page3 of4 pages
5B
4. REFERINCES (pleaseattachthe ftcommerdation letteNAom two personsacquaintedwith your
I certit that my statemenfsin answerto the foregoingquestionsare hue, completeand co[€ct to tle bestof
my knowledgeand belief.
If acceptedfor a tlaining award,I undertaketo :(a) carry out such instructions and abide by suchconditionsas may be stipulatedby both
goverlment aadthe host goverft:ent iD rcspectofthis coulseoftraining;
(b) follow the course of haining, and abide by the rules of tle University or other
establishmentin tvhich I undertaketo hain:
(c) reiain from engagingin political activities, or any form of employmentfor profit or gain;
(d) submitany progressreportswhich may be prescribed;
(e) retum to my homecountry promptly upon the completio! of my courseof haiimg.
I alsofully understandthat if I am granteda fellowship awar4 it may be subsequenilywithdra\rn if I fail ro
makeadequateprogressor for otler sufficieit causedeierminedby the hostGovernment.
Signature
of applicant:.
5, GOVERNMENT AUTHORISATION
: To be compleredby the nominating covemment or the
agency ftom whom the Dominationhasbeen invited.
I cenify thal, to the best ofmy knowledge,
(a) all information suppiied by the nominee is compteteand correct;
(b) the nominee has adequateloorvledge and expe.iencein relaredfields and has adequateEnqlish
proficieDcy for the puryoseofthe fellowship in Thailald.
On retum ftom the fellorvship, the rominee wilt b€ employedin the folowing position :
Title ofpost
Duties and responsibiti€s
Sigmture of responsibleGovemnent ofiicial
Official address:
Date
Page4 of4 pages
59
Attachment
MEDICAL R.EPORT
Name of Nominee
Age : ............Sex:..-.........
Countrv
?hysical Examination(To be fiIled in by physician)
Height.....................ClDs.
Weight ..........,kgs.BloodPressure...................
mm.Hg.
Vision Right.......................
Lefi.
Checkeachitem in appiopdatecolumn
Items
Normal
ceneral
Skin,Scalp
Lymph nodes
Eyes
o
o
o
o
Pulse.-.-........,..-."/Inin.
Eyes............................-.
Withglasses/ Without glasses
Abnormal
Additiolal Comments
o
Ears :
OtoscopicExam
NOSe
Pharynx& tonsils
o
o
Teeth
(\'
Thyroidgland
n
Lungs
Head
Abdomen
Liver
Spleen
o
o
o
Hernia
Externalgenitalia
Rectalexam.
Vertebrae
LOCOmOIOT
Reflexes
Mentalhealthstatus
o
o
o
o
o
o
PageI of2 pages
LABORATORY EXAMINATIONS
Page2 of2 pages
Health StalusCertilication
I confirmthat I am physicallyand mentallyfit andableto carryon an intensivetraining
in Thailand,andthat
I
i
:
(a)
(suchastuberculosis,
I amtiee intbctious
diseases
leprosy,
syphilisandfila asis)
(suchaspsychosis,
andotherconditions
drugaddiction,
andchronicalcoholism)
rrhichcouldpresent
risksfor myselfaswell asothersduing my fellowship;
(b)
I haveno conditions
or defects
whichmightrequiretreatment
duringmy
f€llowship.
(c)
I am not in a stateofpregnancy.
Signatu
re ofapplicant:
Printedname:
Daae:
P a g eI o f l p a g e
962Krung KasemRoad,Bangkok10100Thailand
TeL 6622817633,6622818076
Fax66 22816385,2280 3Bg9
Email: tica@mfa.go.thWebsirer
*ar'\l,.nfa.go.rh
FOROFFICIAL
USEONLY
SCHOLARSIIIP APPLICATION FORM
Important Instructions:
- This applicationfofm is composedoffive partsand shouldbe t)?ed print€d
or
clearly
- Pan 1 to pan 4 should be completedby the candidateand pan 5 by the
governmentaudrodty
- Each questionmust be answeredclearly and completely. Detailed answersare
r€quiredin orde. to makethe mostappropriatearangements.
- Oflicial authority of the nominatingGovernmentlyill formaUy
nominate
and forward three copies of the certified applicatiotr forms to the
TEAILAND INTERNATIONAL DEVELOPMENT COOPERATION
AGENCY through the RoyalThai Ent assyin the nominatingcountry.
' fbe ncmineeis requiredto attachmedicalreport or healthstatuscertification.
- No considerationlyill be given to the late submissionsor incomDlete
applications/documents.
(Pleaseattach
photo$aph here)
Title oiCourse:
Nameof AcademicInstitution:
1. PERSONALDATA
Title
Iram y name/surnametasshofn in
passport)
First name
Sex
O Mr.
O Mis.
O Ms.
City andcountryofbirth
O Male
Date ofbit'l
(DDA4M/YY)
Nationality
6 -''6'
|
I
Manrat
Status
Religion
PageI of4 pages
56
Hor"e-drcss (Pte"s" complet€this section as clear as
F6ik-lFss (Pl"aii comPletethis sectrouasclearas
possible,informarionwill be usedfor tr"avelarraDgemenl) Dossible.infotnatio! will be usedfor ravel
ar:ugemenLi
TelephoneNo :
(Coutrhy CoddArea Coden'lun$e,
Fax
AreaCode/ Number)
Itrternationrl Airport/City for deParture
Email address
Name and adalressofperson to be Dotified in caseolemergency :
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 :'
WRITE
READ
Languages
Mothertongue-...... .. ........
Exellent I
C@d
I
SPEAI{
Fai.
English
English Profrciency Test (pleaseattach)
! rorrr,
score........ I mlr
........,.
I other(speciiy)
EDUCATION R.ECORD
EducationInstitution
ltended
City / Country
;-l
;-_-]
I
Dege€s, Diplomas
and Crnificares
Majorfieldof
study
Have you ever been trained in Thailand?lf yes, what courle, whereand for how long?
tdo nor awlcn o€raNl
For a candidaiefcr a degreecourse,pleasegive a lisl ofreievant publications/researches
Page2 of4 pages
57
2. EMPLOYMENT RXCORD : 1tis importantto givecomplete
information.For eachpostyof have
givedetailsofyour dutiesandresponsibilities,
occupied,
Presentor most recentpost :
Datesfrom
Title ofyour post :
Descriptionof your work
including your persoml respotrs,ibilities
to
Name of organisation;
T)?e of organisation:
Official ad&ess:
Previouspost :
Datesftom
Title of your post I
Descriptionof your work,
including your personalresponsibilities
to
Nameoforganisation:
T)?e of organisation:
Oificial address:
Pleasecontinueon supplementarypagesifnecessary.
3, EXPECTATIONS
et.u
bdon to lle
you
responsibilities
expectto assumeandthe conditioDsexistingin your country in the field of you. training.
(Pleasecontinueon supplementarypagesifnecessary)
Page3 of4 pages
5B
4. REFERINCES (pleaseattachthe ftcommerdation letteNAom two personsacquaintedwith your
I certit that my statemenfsin answerto the foregoingquestionsare hue, completeand co[€ct to tle bestof
my knowledgeand belief.
If acceptedfor a tlaining award,I undertaketo :(a) carry out such instructions and abide by suchconditionsas may be stipulatedby both
goverlment aadthe host goverft:ent iD rcspectofthis coulseoftraining;
(b) follow the course of haining, and abide by the rules of tle University or other
establishmentin tvhich I undertaketo hain:
(c) reiain from engagingin political activities, or any form of employmentfor profit or gain;
(d) submitany progressreportswhich may be prescribed;
(e) retum to my homecountry promptly upon the completio! of my courseof haiimg.
I alsofully understandthat if I am granteda fellowship awar4 it may be subsequenilywithdra\rn if I fail ro
makeadequateprogressor for otler sufficieit causedeierminedby the hostGovernment.
Signature
of applicant:.
5, GOVERNMENT AUTHORISATION
: To be compleredby the nominating covemment or the
agency ftom whom the Dominationhasbeen invited.
I cenify thal, to the best ofmy knowledge,
(a) all information suppiied by the nominee is compteteand correct;
(b) the nominee has adequateloorvledge and expe.iencein relaredfields and has adequateEnqlish
proficieDcy for the puryoseofthe fellowship in Thailald.
On retum ftom the fellorvship, the rominee wilt b€ employedin the folowing position :
Title ofpost
Duties and responsibiti€s
Sigmture of responsibleGovemnent ofiicial
Official address:
Date
Page4 of4 pages
59
Attachment
MEDICAL R.EPORT
Name of Nominee
Age : ............Sex:..-.........
Countrv
?hysical Examination(To be fiIled in by physician)
Height.....................ClDs.
Weight ..........,kgs.BloodPressure...................
mm.Hg.
Vision Right.......................
Lefi.
Checkeachitem in appiopdatecolumn
Items
Normal
ceneral
Skin,Scalp
Lymph nodes
Eyes
o
o
o
o
Pulse.-.-........,..-."/Inin.
Eyes............................-.
Withglasses/ Without glasses
Abnormal
Additiolal Comments
o
Ears :
OtoscopicExam
NOSe
Pharynx& tonsils
o
o
Teeth
(\'
Thyroidgland
n
Lungs
Head
Abdomen
Liver
Spleen
o
o
o
Hernia
Externalgenitalia
Rectalexam.
Vertebrae
LOCOmOIOT
Reflexes
Mentalhealthstatus
o
o
o
o
o
o
PageI of2 pages
LABORATORY EXAMINATIONS
Page2 of2 pages
Health StalusCertilication
I confirmthat I am physicallyand mentallyfit andableto carryon an intensivetraining
in Thailand,andthat
I
i
:
(a)
(suchastuberculosis,
I amtiee intbctious
diseases
leprosy,
syphilisandfila asis)
(suchaspsychosis,
andotherconditions
drugaddiction,
andchronicalcoholism)
rrhichcouldpresent
risksfor myselfaswell asothersduing my fellowship;
(b)
I haveno conditions
or defects
whichmightrequiretreatment
duringmy
f€llowship.
(c)
I am not in a stateofpregnancy.
Signatu
re ofapplicant:
Printedname:
Daae:
P a g eI o f l p a g e