Application Form for Sustainable Development Programme

 

  1. Applicant

 

Name:

Home Address:

 

Citizenship:                                      Country of Birth:

Date of Birth:

E-mail:                      Phone #:                      Fax #:

Organization Address:

 

 

Area of Expertise:

 

 

  1. Time Period (Between 01/01/2007 – 31/12/2007)

     

 Date of Departure:

 Date of Return:

 

  1. Receiving Institution

 

(Supervisor/Advisor/Coordinator)

Name:

Organization Address:

 

E-mail:                      Phone #:                      Fax #:

 

 

  1. Sending Institution (Technical Committee / Member Society)

 

Name of TC/MS:

 

(Supervisor/Advisor/Coordinator)

Name:

Organization Address:

 

E-mail:                      Phone #:                      Fax #:

 

 

 

 

 

 

 

  1. Describe contribution for Developing Country

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Describe the benefit for the contributor’s scholar/ Professional

 

e.g. field work for Ph.D., Professional experience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                        Date:

 

                                                        Signature of the Applicant

 

 

                                                        Signature of the supervisor (receiving organization)

 

 

                                                        Signature of the supervisor (sending organization)