TBCTA ReTraC Asia FM UGMfk.ugm.ac.id/wp-content/uploads/2016/05/Application-For… · Web...
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GADJAH MADA UNIVERSITY REGIONAL TRAINING CENTER FOR HEALTH RESEARCH SUPPORTED BY WHO-TDR Course Application Form 2 nd Batch of Regional Course on Good Clinical Laboratory Practice - GCLP (September 7 – 9, 2016) Application Deadline: Sponsorship: July 7, 2016, Normal: August 7, 2016 1. APPLICANT INFORMATION (2-3 persons per institution) (Please fill in the name exactly as it is in applicant passport) Personal Information – Applicant 1 Title: Prof/Dr/Ms/Mr. Family Name First Name (s) (as in passport) Organization Office Address Postal Code/ City Country Fax Telephone number including country code Home Address Postal Code/ City Country Email address Passport number Date of birth Place of birth (city, country) Page 1 of 5
Transcript of TBCTA ReTraC Asia FM UGMfk.ugm.ac.id/wp-content/uploads/2016/05/Application-For… · Web...
TBCTA ReTraC Asia FM UGM
Gadjah Mada University Regional Training Center for Health Research
supported by WHO-TDR
Course Application Form
2nd Batch of Regional Course on
Good Clinical Laboratory Practice - GCLP (September 7 9, 2016)
Application Deadline: Sponsorship: July 7, 2016, Normal: August 7, 2016
1. APPLICANT INFORMATION (2-3 persons per institution)
(Please fill in the name exactly as it is in applicant passport)
Personal Information Applicant 1
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address
Postal Code/ City
Country
Fax
Telephone number including country code
Home Address
Postal Code/ City
Country
Email address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English
Written: Average___ Good___ Excellent ___
Spoken: Average___ Good___ Excellent ___
Computer literacy
Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____
Internet: Proficient___ Need Help___ Never Used____
Personal Information Applicant 2
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address
Postal Code/ City
Country
Fax
Telephone number including country code
Home Address
Postal Code/ City
Country
Email address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English
Written: Average___ Good___ Excellent ___
Spoken: Average___ Good___ Excellent ___
Computer literacy
Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____
Internet: Proficient___ Need Help___ Never Used____
Personal Information Applicant 3
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address
Postal Code/ City
Country
Fax
Telephone number including country code
Home Address
Postal Code/ City
Country
Email address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English
Written: Average___ Good___ Excellent ___
Spoken: Average___ Good___ Excellent ___
Computer literacy
Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____
Internet: Proficient___ Need Help___ Never Used____
2. SPONSORSHIP
WHO-TDR through the course organizer offers full scholarship for 7 participants of SEAR countries which covers course materials, faculty fees, lodging (not applicable for residence of Yogyakarta/GMU staff), lunch and coffee breaks during the course, as well as travel expenses (economic airfare) from country of home institution.
3. REGISTRATION
This 2nd Batch of Regional GCLP Course is designed as a 3 day intensive program with a maximum of 25 participants.
Registration open : April,1 August 7, 2016
Course fee per person :
a. Sponsorship: April 1 July 7, 2016 : FREE (please see 3. sponsorship)
b. Early Bird: April 1 July 31, 2016 : Rp. 4,000,000,- (US$ 320)
c. Normal: August 1 7, 2016 : Rp. 5,000,000,- (US$ 400)
Attach the following to this application form (can be downloaded in http://retrac.fk.ugm.ac.id):
The participants typewritten detailed Curriculum Vitae
Motivation letter
A scanned or copy of participants passport
Recommendation letter from head of institution.
Send the application package by the deadline (Sponsorship: July 7, 2016, Normal: August 7, 2016) by fax, e-mail or post to:
Research & Collaboration Unit, Centre for Tropical Medicine 2nd Floor
Gedung PAU - UGM, Jl. Teknika Utara, Barek, Yogyakarta 55281, Indonesia
Tel: (+62274) 547147 Fax: (+62274) 547147
Contact Person:
dr. Ktut Rentyasti Palupi, MPH (Email: [email protected])
Failure to provide all of the information requested may result in the rejection of your application.
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