NOMINATION FORM

ASEAN YOUTH CAMP: ASEAN YOUTH STEPPING TOWARDS ENVIRONMENTAL

SUSTAINABILITY
24 – 30 APRIL 2018
Thailand
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PART ONE: INFORMATION ABOUT THE ORGANISATION

Name of the nominating
organisation:

Address of the nominating

organisation:

Name/designation of nominator:

Email:

Phone (with country and area

code):

Fax (with country and area

code):

PART TWO: PARTICULARS OF NOMINEE

Name (As in passport and underline surname):

Affix Recent Passport

Nationality: Size Photograph Here

Gender: Date of Birth: Age:

Passport No: Place of Issue: Date of Issue: Date of Expiry:

Home Address:

Home Tel No: Mobile: Email:

(with country and area
code)

Name of university/school

Faculty / Course /
Year of Study:

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Religion:

Food Forbidden on
Religious Grounds, etc.:
Hobbies/Areas of Interest:

Name of Next-of-kin/
Relationship:
Address of Next-of-kin:

Contact No.
Home Tel: Office Tel: Mobile:
of Next-of-kin:
(with country and area
code)
Email:
Do you have any medical * Yes / No. If yes, please state details:
allergies or conditions?

Is English your first language? ____Yes _____No

Please indicate your English skills:

Speaking ___excellent ___good ___fair
Listening ___excellent ___good ___fair
Reading ___excellent ___good ___fair
Writing ___excellent ___good ___fair

Your involvement / experiences in environment (Please attach separate sheet)

1. Please give a short description of your involvement/experiences in environmental activities / projects.

2. What contribution can you make (as youth) regarding Sustainable Development Goals (SDGs) and its related
issues in your country after attending the Workshop? Please briefly explain your ideas.

Signature of nominator Signature of applicant

--------------------------------- ------------------------------------------

Please kindly send completed form by 04 April 2018 to

kaderlhk.puslatmas@gmail.com

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