WORLD HEALTH ORGANIZATION SOUTH –EAST ASIA REGION ATTACH RECENT

WORLD HEALTH ORGANIZATION

SOUTH –EAST ASIA REGION

Attach recent photograph here

STUDY TOUR APPLICATION

IMPORTANT

Please answer each question clearly and completely. Detailed answers are required to ensure the most appropriate study arrangements. Please submit four typewritten copies complete in a language appropriate to the country of study. If necessary additional pages of the same size may be attached. Be sure to sign and date the form.

1. PERSONAL DATA

1) Family name (Surname) First/other names Dr Mr Mrs Miss Ms

           

2) City and country of birth

     

Date of Birth

     

(day/month/year)

Nationality

     

Marital status

     

Sex

M F

3) Mailing Address
     

Office telephone      

Office fax      

E-mail:      

4) Home Address     

Home telephone      

Home fax      

5) Name and address of person to be notified in case of emergency Relationship      

     

Office telephone       E-mail       Home telephone      

Fax       Telex       Fax      

2. LANGUAGE ABILITY MOTHER TONGUE:     

For language(s) other than mother tongue enter below the
appropriate letter from the code system at right to indicate your level of skill.

Understanding of spoken language

A I understand at the level of university instruction

B I understand at the level of normal conversation

C I understand simple daily usage

Speaking ability

A I speak at the level of university discussion

B I speak well enough to engage in normal

conversation

C I speak adequately to meet limited social needs

Reading ability

A I can read without difficulty all technical material in my field

B I can read with some difficulty all technical

material in my field

C I can read newspaper articles and similar
material

Writing ability

A I can write technical papers and reports
easily

B I can write technical reports with some
difficulty

C I can write ordinary correspondence

Language

Understand

Speak

Read

Write

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. STUDY TOUR / FELLOWSHIP PREVIOUSLY UNDERTAKEN / AWARDED

Dates (From / To)

Awarding Organization

Place of study

Field of study

Language used

     

     

     

     

     

4. EDUCATION

Provide details in chronological order. Give full name of the Institution and title of degrees/certificates/diplomas.
Exclude primary/ secondary school(s) if you have a university qualification. Include postgraduate studies in your
professional fields.

Dates (From / To)

Institution

(name, city and country)

Qualification/Degree Obtained

Major fields of study

Language

Used

     

     

     

     

     

5. EMPLOYMENT RECORD

Beginning with your present or most recent employment/position, provide details of your duties, responsibilities and activities,
describing what you are doing (supervising, planning, training, etc.).

a. Present post

List your specific duties

From:       To: present

     

Title of your post      

Name and address of employer

     

Name and address of supervisor

     

Type of employment

Public service Private

Teaching Research Other

b. Previous post

List your specific duties

From:       To:      

     

Title of your post      

Name and address of employer      

Name and address of supervisor

     

Type Public service Private

Teaching Research Other

6. PROPOSED FIELD OR SUBJECT OF STUDY

     

7. SPECIFIC OBJECTIVES AND EXPECTED OUTPUT OF STUDY

State clearly the specific objectives of your study tour, as far as possible in "measurable" terms. Show the relevance of the objectives
to the programmes product / activities and identify the expected outcome/outputs.

(1)      

(2)      

(3)      

8. PROPOSED ACTIVITIES

State precisely and in detail the particular study visits you consider most suitable to the objectives of your study tour. It is on the
following information provided by you that the responsible officer will plan your study Programme. It is of utmost importance that
he/she should fully understand your wishes.

State precisely, and in detail, what you wish to learn / observe

     

Place / institution to be visited

     

Country

     

Duration of visit

     

9. CONCLUSION

1. I certify that the above statements are correct and complete to the best of my knowledge. I will furnish a report to the WHO upon completion of the study tour.

_______________________ ___________

Signature Date

2. WR's endorsement / comments:

_______________________ _____________

Signature Date