Application Form.

Send to Sekretariat PR IV Unand
Email to:
seminar.pr4.unand@gmail.com
sekretariat.pr4.unand@gmail.com

PARTICIPANT REGISTRATION FORM
I wish to participate in the
International Competitive Proposal Writing Workshop
Kampus Universitas Andalas, Padang
12-13 November and 19-20 November 2010
Full Name

     

Name in Certificate

     

Postal Address

     

Phone

     

Fax

     

E-Mail

     

Mobile

     

3

Profession

     

4

Date, place and country of birth

5

College and/or university education

1

2

6

Name and place

     

From

     

Main studies

     

Thesis or major

     

Male

     

     

To

English language proficiency ( fair F, good G, excellent E)
Read
F

Write
G

E

F

Speak
G

E

F

Was English the language of instruction in secondary school/ university? Y

7

Degree      

G

Understand
E

F

N

Present professional employment (use additional sheet if necessary)
Job Title

     

From

Employer, name

     

Employer, address

     

Type of organization: government
Phone

     

semi government
Fax

private
     

Responsibilities:
     
     

8 In case you are involved in the execution of a specific project:
Project name

     

Job Title

     

Responsibilities      
Location

     

     

E-mail

     

G

E

Female

9

Executing Agency

     

Financing provided by

     

Could you explain why you are interested to become a participant in this course?
     
     
     

9

Could you please write an idea which could be proposed to be proposal?, please refer following websites to find any potential donors: http://www.cknetina.org/index2.php?menu=donors

Date:      

Signature applicant: