APPENDIX OF APPLICATION FORM
for
Web-based Networking
Please submit all pertinent documents and your answers to this questionnaire in typewritten form (page 7 - 10) together with your Fellowship Application Form.

Download Application Form for Web-based Networking in PDF format (139 KB)

TITLE Mr.
Ms.
Mrs.
Dr.
GENDER MALE
FEMALE
NAME (capital letter)    
 
FAMILY NAME GIVEN NAME MIDDLE NAME
HOME ADDRESS:





TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):
EMAIL ADDRESS:
NAME OF THE ORGANIZATION:



ADDRESS:



TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):
EMAIL ADDRESS:
DISABILITIES (IF ANY)
 
YES
NO
TYPE OF DISABILITIES: Physical Disability Hearing Disability
Visual Disability Intellectual Disability
Mental Disability Other (                  )
USAGE OF ASSISTIVE DEVICES: YES NO
DETAILS OF YOUR ASSISTIVE DEVICES:
  Power/electronic wheelchair ( Wet battery Dry battery)
  Wheelchair
  Crutch
  White cane
  Other ( )
USAGE OF SIGN LANGUAGE (SL):
 English SL  Other SL (                         )
DIETARY REQUIREMENT (IF ANY)

I hereby certify that all the provided information is correct, accurate and complete to the best of my knowledge.

In the event that I suffer injury, illness or death during the course of my participation in the program/course, I shall hold the Royal Thai Government, the Government of Japan and/or the Asia-Pacific Development Center on disability harmless and without any liability whatsoever for compensation towards myself, my legal representatives and/or my heirs. Should I cause any person loss of property, injury, illness or death during the course of my participation the program/course, I shall be fully responsible and liable for the said person without reference whatsoever to the Royal Thai Government, the Government of Japan and/or the Asia-Pacific Development Center on Disability.

 

 

SIGNATURE OF NOMINEE ………………………………………………………………

PRINTED NAME OF NOMINEE (                         )
 
DATE:
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   Download Questionnaire for Web-based Networking (PDF format)
size: 48 KB
Questionnaire

Q1     Have you ever heard about information accessibility for persons with disabilities?
               If so, please write what you know about information accessibility.
               If not, please write what you think about information accessibility. ……………………………………………………………………………………………………………………………………
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Q2.     Does your organization have publications for public relations? (e.g. Newsletter,
Pamphlet, Annual Report, Video etc.)
                If so, please describe contents of the media and how to distribute it.
                If not, please explain why do not have it. ……………………………………………………………………………………………………………………………………
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Q3.     Does your organization have Internet Access?
               Yes                                    No
                If yes, how fast is it?
                    56 k modem or less
                    Broad Band ______ kbps
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Q4.     Does your organization have website?
                If so, what is the most difficult matter when you maintain the website?
                If not, do yo have a plan to open website?
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Q5.     Can you recommend website, which you are relying on most when you
collect disability-related information?
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Q5a.     How often do you check the website?
1) Couple of times a day   2) Once a day    3) A few times a week
4) Once a week             5) Once a month or less

Q6.     Have you ever visited APCD website?

1) Often     2) A few times     3)Never

Q7.     What kind of information do you expect APCD to have in the website?
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Q8.     Are you happy with Accessibility/Usability of the APCD website?
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