8/12/2019 Formato de Aplicacion Formato de Aplicación para beca Sufficiency Economy and Universal Health Coverage

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Ministry of Foreign AffairsThailand International Development Cooperation Agency (TICA)

Government Complex, !ilding ("o!th #one), $ th Floor,Chaeng%attana &oad, ang'o' * , Thailand

Tel+ ** - . ext+ /-- . Fax * /- 0-*., * /- $/.1mail2 tica3mfa+go+th 4e5site2 %%%+tica+thaigov+net

F16674"8I9 A996ICATI7: F7&M

I:"T&;CTI7:"This application form is composed of five parts (part A to part E) and should becompleted in triplicate. Part A to part D should be completed by the candidate and part E

by the government authority. All parts m!st 5e filled in type%ritten form+ 1ach<!estion m!st 5e ans%ered clearly and completely+ Detailed ans%ers are re<!iredin order to ma'e the most appropriate arrangements+ Official authority of thenominating Government ill then for ard three copies of the certified application formsto the Thailand !nternational Development "ooperation Agency (T!"A)# theGovernment "omple$# %uilding % (&outh 'one)# th loor# "haeng atta *oad# +a,si#District %ang,o, - /-/# Thailand# through the *oyal Thai Embassy or "onsulate in thenominating country. The nominee is re0uired to attach medical report or health statuscertification. :o consideration %ill 5e given to the late s!5missions or incompleteapplications=doc!ments+Co!rse :ame 1

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A+ 91&"7:A6 8I"T7&>

Title Family name Middle name Given name "ex(as sho%n in passport and 'indly attach the copy of yo!r passport, information

%ill 5e !sed for travel arrangement)

ο 3r.ο 3rs.ο 3s.

ο 3aleο emale

"ity and country of birth 4ationality Date of birth(DD533566)

Age 3arital&tatus

*eligion

7or, address (Please complete this section as clear as possible# information ill be used for travel arrangements.)

8ome address (Please complete this section as clear as possible# information ill be used for travelarrangements.)

999999999999999999999999999999999999999999999999 999999999999999999999999999999999999999999999999 999999999999999999999999999999999999999999999999

99999999999999999999999999999999999999999999999 99999999999999999999999999999999999999999999999 99999999999999999999999999999999999999999999999

a$ 4o1 ("ountry "ode 5Area "ode 5

4umber)

Telephone 4o1 Telephone 4o1a$ 4o1

International Airport=City for depart!re 1

;pdate email address 2 4ame and address of person to be notified in case of emergency1 Telephone 4o1 *elationship of this person to you1

(Pleaseattach

hoto ra h

8/12/2019 Formato de Aplicacion Formato de Aplicación para beca Sufficiency Economy and Universal Health Coverage

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Page 1 of 3 pages6ang!ages 1 &1AD 4&IT1 "91A? 3other tongue 122222222. E$cellent Good air E$cellent Good air E$cellent Good air

EnglishOther222222222222.

1nglish 9roficiency Test (please attach) T71F6 "core 222. I16Ts "core 222.. (only a candidate for a degree course) 7ther (specify) 22222222222222222222.1D;CATI7: &1C7&D

Education !nstitution "ity 5 "ountry6ears Attended

Degrees# Diplomasand "ertificates

&pecial fields ofstudyrom To

8ave you ever been trained in Thailand: !f yes# hat course# here and for ho long:

222222222222222222222222222222222222222222222222

222222222222222222222222222222222222222222222222or a candidate for a degree course# please give a list of relevant publications5researches (do not attach details)

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222222222222222222222222222222222222222222222222

222222222222222222222222222222222222222222222222

222222222222222222222222222222222222222222222

+ 1M967>M1:T &1C7&D2 !t is important to give complete information. or each post you haveoccupied# give details of your duties and responsibilities.

Present or most recent post1Dates from 999999999999999 to 9999999999999999

Description of your or,#including your personal responsibilities

Title of your post1

4ame of organisation1

Type of organisation1

Official address1

Previous post1Dates from 999999999999999 to 99999999999999999

Description of your or,#including your personal responsibilities

Title of your post1

4ame of organisation1

Type of organisation1

Official address1

8/12/2019 Formato de Aplicacion Formato de Aplicación para beca Sufficiency Economy and Universal Health Coverage

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Page 2 of 3 pagesC+ 1@91CTATI7:"Please describe the practical use you ill ma,e of this training5study on your return home in relation to theresponsibilities you e$pect to assume and the conditions e$isting in your country in the field of your training.(give the attached paper# if necessary)

D+ &1F1&1:C1" (only a candidate for a degree course please attaches the recommendation letters from t o personsac0uainted ith your academic and professional e$periences.)! certify that my statements in ans er to the foregoing 0uestions are true# complete and correct to the best of my,no ledge and belief.

!f accepted for a training a ard# ! underta,e to 1;(a) carry out such instructions and abide by such conditions as may be stipulated by both the nominating government

and the host government in respect of this course of training<(b) follo the course of training# and abide by the rules of the =niversity or other institutions or establishment in

hich ! underta,e to train<(c) refrain from engaging in political activities# or any form of employment for profit or gain<(d) submit any progress reports hich may be prescribed<(e) return to my home country promptly upon the completion of my course of training.

! also fully understand that if ! am granted a fello ship a ard# it may be subse0uently ithdra n if ! fail toma,e ade0uate progress or for other sufficient cause determined by the host Government.

&ignature of applicant1 22222222222222222222....

Printed name1 2222222222222..22222222222

Date1 22222222222222222.22222.2222

1+ G7 1&:M1:T A;T87&I"ATI7: 1 To be completed by the nominating Government or theagency from hom the nomination has been invited.

! certify that# to the best of my ,no ledge#(a) all information supplied by the nominee is complete and correct<(b) the nominee has ade0uate ,no ledge and e$perience in related fields and has ade0uate English

proficiency for the purpose of the fello ship in Thailand. On return from the fello ship# the nominee ill be employed in the follo ing position1

Title of post 22222.22222.222222222222222222222222..22..

Duties and responsibilities22222222222.2..222.2222222.22222222..

222.222222222222222222222222222222.222222222

2222222222222222 Signature of responsible Government official

Official stamp1 Title1 ...222222.2222222.2222.22222

Organisation1 22222222222222222222.

Official address1 2222222222222222222

2222222222222222222.

2222222222222222222.

Date1 2222222222222222

8/12/2019 Formato de Aplicacion Formato de Aplicación para beca Sufficiency Economy and Universal Health Coverage

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Page 3 of 3 pages

Attachment

M1DICA6 &197&T

4ame of 4ominee 22222222222222222222222222"ountry22222.2222222222222222222222222

Age 1 222 &e$ 1 22222

Physical E$amination (To 5e filled in 5y physician)

8eight 2222. "ms. 7eight 22....2.,gs. %lood Pressure 222.2 mm.8g. Pulse 22.2..5min.

>ision *ight .2..222 +eft 222...... Eyes 222222.2... 7ith glasses 5 7ithout glasses

"hec, each item in appropriate column

Items :ormal A5normal Additional Comments

General 22222222222222222222

&,in# &calp 22222222222222222222

+ymph nodes 22222222222222222222

Eyes 22222222222222222222

Ears 22222222222222222222

7toscopic 1xam

4ose 22222222222222222222Pharyn$ ? tonsils 22222222222222222222

Teeth 22222222222222222222

Thyroid gland 22222222222222222222

+ungs 22222222222222222222

8eart 22222222222222222222

Abdomen 22222222222222222222

+iver 22222222222222222222

&pleen 22222222222222222222

8ernia 22222222222222222222

E$ternal genitalia 22222222222222222222

*ectal e$am 22222222222222222222

>ertebrae 22222222222222222222

+ocomotor 22222222222222222222

*efle@es 22222222222222222222

3ental health status 22222222222222222222

8/12/2019 Formato de Aplicacion Formato de Aplicación para beca Sufficiency Economy and Universal Health Coverage

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Page 1 of 2 pages

6A 7&AT7&> 1@AMI:ATI7:"

%lood group 22222..222. %lood film for malaria 2..2..2222222.. 8b 222222.2. gm

7%" 22222222222222222 "ells5cu.mm.

Differential P34 22222. +ymp 222.22 3ono 222..22 Eos 222..2..

%aso 2222222..2 %and 222222222 %last 2222222.

=rinalysis 1 "olour 222222.. &p. Gr 2222222 p8 22222. &ugar 222222222.

Alb 222222. %lood 222..222. Betones 22.222. %lie2222..22222..

3icro 1 7%" 222.22.58P .# *%" 2222258P .# Epethelial22222. 58P .

"asts 2222222225 8PD.# Others 22222222222222..22222222

&tool e$amination for parasite ? Ova 2222222222222222222222222222222..

"hest C *ay report 2222222222222222.2222222222222222222222

=rine pregnancy test 22222222222222222222222222222222222222..

!s the nominee able physically and mentally to carry on intensive study a ay from home:

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!s the nominee free from infectious diseases (such as tuberculosis# leprosy# syphilis and filariasis) and other conditions

(such as psychosis and drug addiction) hich could present ris,s for anyone during the fello ship period:

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Does the nominee have any condition or defect hich might re0uire treatment during the fello ship period:

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! certify that the applicant is medically fit to underta,e a course in Thailand.

ull name and address of Physician signature 22222222222..3.D.

E$amining physician (printed) (222222222222222222)

2222222222222 Date22222222222222222222

2222222222222

2222222222222

Telephone1 222222222..

(printed)

e;mail1 22222222222..

Page 2 of 2 pages