Thailand International Development Cooperation Agency (TICA)
Government Complex, !ilding ("o!th #one), $ th Floor, Chaeng%attana &oad, ang'o' ()*(), Thailand Tel+ ,, **)- .))) ext+ /--). Fax ,, *(/- 0-*., *(/- $/.( 1mail2 tica3mfa+go+th 4e5site2 %%%+tica+thaigov+net F16674"8I9 A996ICATI7: F7&M I:"T&;CTI7:" This application form is composed of five parts (part A to part E) and should be completed in triplicate. Part A to part D should be completed by the candidate and part E by the government authority. All parts m!st 5e filled in type%ritten form+ 1ach <!estion m!st 5e ans%ered clearly and completely+ Detailed ans%ers are re<!ired in order to ma'e the most appropriate arrangements+ Official authority of the nominating Government ill then forard three copies of the certified application forms to the Thailand !nternational Development "ooperation Agency (T!"A)# the Government "omple$# %uilding % (&outh 'one)# ( th )loor# "haengatta *oad# +a,si# District %ang,o, -./-/# Thailand# through the *oyal Thai Embassy or "onsulate in the nominating country. The nominee is re0uired to attach medical report or health status certification. :o consideration %ill 5e given to the late s!5missions or incomplete applications=doc!ments+ Co!rse :ame1 222222222222222222222222222222222222222222222222
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)
3r. 3rs. 3s. 3ale )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 travel arrangements.) 999999999999999999999999999999999999999999999999 999999999999999999999999999999999999999999999999 999999999999999999999999999999999999999999999999 99999999999999999999999999999999999999999999999 99999999999999999999999999999999999999999999999 99999999999999999999999999999999999999999999999 )a$ 4o1 ("ountry "ode 5 Area "ode 5 4umber) Telephone 4o1 Telephone 4o1 )a$ 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 (Please attach photograph Page 1 of 3 pages 6ang!ages 1 &1AD 4&IT1 "91A? 3other tongue 122222222. E$cellent Good )air E$cellent Good )air E$cellent Good )air English Other222222222222. 1nglish 9roficiency Test (please attach) T71F6 "core 222. I16Ts "core 222.. (only a candidate for a degree course) 7ther (specify) 22222222222222222222. 1D;CATI7: &1C7&D Education !nstitution "ity 5 "ountry 6ears Attended Degrees# Diplomas and "ertificates &pecial fields of study )rom To 8ave you ever been trained in Thailand: !f yes# hat course# here and for ho long: 222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222 )or a candidate for a degree course# please give a list of relevant publications5researches (do not attach details) 222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222 + 1M967>M1:T &1C7&D2 !t is important to give complete information. )or each post you have occupied# give details of your duties and responsibilities. Present or most recent post1 Dates from 999999999999999 to 9999999999999999 Description of your or,# including your personal responsibilities Title of your post1 4ame of organisation1 Type of organisation1 Official address1 Previous post1 Dates from 999999999999999 to 99999999999999999 Description of your or,# including your personal responsibilities Title of your post1 4ame of organisation1 Type of organisation1 Official address1 Page 2 of 3 pages C+ 1@91CTATI7:" Please describe the practical use you ill ma,e of this training5study on your return home in relation to the responsibilities you e$pect to assume and the conditions e$isting in your country in the field of your training. (give the attached paper# if necessary) D+ &1F1&1:C1" (only a candidate for a degree course please attaches the recommendation letters from to persons ac0uainted ith your academic and professional e$periences.) ! certify that my statements in anser to the foregoing 0uestions are true# complete and correct to the best of my ,noledge and belief. !f accepted for a training aard# ! 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 felloship aard# it may be subse0uently ithdran if ! fail to ma,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+ G7A1&:M1:T A;T87&I"ATI7:1 To be completed by the nominating Government or the agency from hom the nomination has been invited. ! certify that# to the best of my ,noledge# (a) all information supplied by the nominee is complete and correct< (b) the nominee has ade0uate ,noledge and e$perience in related fields and has ade0uate English proficiency for the purpose of the felloship in Thailand. On return from the felloship# the nominee ill be employed in the folloing position1 Title of post 22222.22222.222222222222222222222222..22.. Duties and responsibilities22222222222.2..222.2222222.22222222.. 222.222222222222222222222222222222.222222222 2222222222222222 Signature of responsible Government official Official stamp1 Title1 ...222222.2222222.2222.22222 Organisation1 22222222222222222222. Official address1 2222222222222222222 2222222222222222222. 2222222222222222222. Date1 2222222222222222 Page 3 of 3 pages Attachment M1DICA6 &197&T 4ame of 4ominee 22222222222222222222222222 "ountry22222.2222222222222222222222222 Age 1 222 &e$ 1 22222 Physical E$amination (To 5e filled in 5y physician) 8eight 2222. "ms. 7eight 22....2.,gs. %lood Pressure 222.2 mm.8g. Pulse 22.2..5min. >ision *ight .2..222 +eft 222...... Eyes 222222.2... 7ith glasses 5 7ithout glasses "hec, each item in appropriate column Items :ormal A5normal Additional Comments General 22222222222222222222 &,in# &calp 22222222222222222222 +ymph nodes 22222222222222222222 Eyes 22222222222222222222 Ears 22222222222222222222 7toscopic 1xam 4ose 22222222222222222222 Pharyn$ ? 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 Page 1 of 2 pages
6A7&AT7&> 1@AMI:ATI7:" %lood group 22222..222. %lood film for malaria 2..2..2222222.. 8b 222222.2. gmA 7%" 22222222222222222 "ells5cu.mm. Differential P34 22222. A +ymp 222.22 A 3ono 222..22 A Eos 222..2.. A %aso 2222222..2 A %and 222222222 A %last 2222222. A =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$amination for parasite ? Ova 2222222222222222222222222222222.. "hest C D *ay report 2222222222222222.2222222222222222222222 =rine pregnancy test 22222222222222222222222222222222222222.. !s the nominee able physically and mentally to carry on intensive study aay from home: 222222222222222222222222222222222222222222222222 !s the nominee free from infectious diseases (such as tuberculosis# leprosy# syphilis and filariasis) and other conditions (such as psychosis and drug addiction) hich could present ris,s for anyone during the felloship period: 222222222222222222222222222222222222222222222222 Does the nominee have any condition or defect hich might re0uire treatment during the felloship period: 222222222222222222222222222222222222222222222222 ! certify that the applicant is medically fit to underta,e a course in Thailand. )ull name and address of Physician signature 22222222222..3.D. E$amining physician (printed) (222222222222222222) 2222222222222 Date22222222222222222222 2222222222222 2222222222222 Telephone1 222222222.. (printed) e;mail1 22222222222.. Page 2 of 2 pages