Fellowship Application Form

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DEPARTMENT OF TECHNICAL AND ECONOMIC COOPERATION
926 Krung Kasem Road, Bangkok 10100, Thailand
Tel. 66 2280 0980 Fax. 66 2281 7148, 2280 1248
Email: dtec-gov@inet.co.th Website: www.dtec.thaigov.net

FELLOWSHIP APPLICATION FORM
INSTRUCTIONS
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 in typewritten form. Each question must be answered clearly and completely. Detailed answers are required in order to make the most appropriate arrangements. Official authority of the nominating Government will then forward three copies of the certified application forms to the Department of Technical and Economic Cooperation, 962 Krung Kasem Road, Bangkok 10100, Thailand, through the Royal Thai Embassy in the nominating country. The nominee is required to attach medical report or health status certification. 		(Please attach photograph here)
Course Name:
…………………………………………………………………………………………………………………………………………………………………………
A. PERSONAL HISTORY
Title Family name (as shown in passport) Given names Sex
Mr.
Mrs.
Ms. 		    Male.
Female.
City and Country of Birth Nationality Date of Birth
(DD/MM/YY)		 Age Marital Status Religion
           
Work address (Please complete this section as clear as possible, information will be used for travel arrangement.) Home address (Please complete this section as clear as possible, information will be used for travel arrangement.)










Fax No: (Country Code/
Area Code/Number)		 Telephone No: Telephone No:
    International Airport/City for departure:
Email Address:  
Name and address of person to be notified in case of emergency:



Telephone No:
Relationship of this person to you:

 

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Language: READ WRITE SPEAK
Mother tongue: Excellent Good Fair Excellent Good Fair Excellent Good Fair
English                  
                   
English Proficiency Test (please attach)
 TOEFL Score…………… IELTS Score……………
(only candidate for a degree course) Other (specify)………………………………………
Education Record
Education Institution City/Country Years Attended Degrees, Diplomas and Certificates Special Fields of Study
    From To    
 









       
Have you ever been trained in Thailand? If so, what course, where and for how long?
For a candidate for a degree course, please give a list of relevant publications/researches (do no attach details).
B. EMPLOYMENT RECORD: It is important to give complete information. For each post you have occupied, give details of your duties and responsibilities.
Present or most recent post:
Dates from ____________to______________		 Description of your work,
including your personal responsibilities
Type of your post:

  
Name of organization:

  
Type of organization:

  
Official address:


  
Previous post:
Dates from _____________to_____________		 Description of your work,
including your personal responsibilities
Type of your post:

  
Name of organization:

  
Type of organization:

  
Official address:


  

 

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C. EXPECTATIONS
Please describe the practical use you will make of this training/study on your return home in relation to the responsibilities you expect to assume and the conditions existing in your country in the field of your training/study (give the attached paper if necessary).

 

 
D. REFERENCES (only a candidate for a degree course, please attach the recommendation letters from two persons acquainted with your academic and professional experiences)

I certify that my statements in answer to the foregoing questions are true, complete and correct to the best of my knowledge and belief.

If accepted for a training award, I undertake to:-
  1. 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;
  2. follow the course of training, and abide by the rules of the University or other institutions or establishment in which I undertake to train;
  3. refrain from engaging in political activities, or any form of employment for profit or gain;
  4. submit any progress reports which may be prescribed;
  5. return to my home country promptly upon the completion of my course of training.

I also fully understand that if I am granted a fellowship award, it may be subsequently withdrawn if I fail to make adequate progress or for other sufficient cause determined by the host Government.
  Signature of applicant:………………………………………
Printed name:……………………………………………………
Date:…………………………………………………………………
E. GOVERNMENT AUTHORISATION: To be completed by the nominating Government or the agency from whom the nomination has been invited.

I certify that, to the best of my knowledge,

  1. all information supplied by the nominee is complete and correct;
  2. the nominee has adequate knowledge and experience in related fields and has adequate English proficiency for the purpose of the fellowship in Thailand.

On return from the fellowship, the nominee will be employed in the following position:

Title of post………………………………………………………………………………………………………………………………
Duties and responsibilities…………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
     Official stamp: ……………………………………………………………………………
Signature of responsible Government official
Title:……………………………………………………………………
Organization:………………………………………………………
Official address:…………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………


Date:……………………………………………………………………

 

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Attachment
 
MEDICAL REPORT
Name of Nominee…………………………………………………………………………………… Age:…………… Sex:……………
Country:…………………………………………………………………………………………………
Physical Examination (To be filled in by physician)
Height……………cm.      Weight……………kg. Blood Pressure……………mm .Hg.      Pulse……………/min. Vision     Right……………     Left…………… Eyes…………………………      With glasses/Without glasses
Check each item in appropriate column
Item Normal Abnormal Additional Comments
General …………………………………………………………………
Skin,Scalp …………………………………………………………………
Lymph nodes …………………………………………………………………
Eyes …………………………………………………………………
Ears: …………………………………………………………………
 
Otoscopic Exam
Nose …………………………………………………………………
Pharynx & tonsils …………………………………………………………………
Teeth …………………………………………………………………
Thyroid gland …………………………………………………………………
Lungs …………………………………………………………………
Heart …………………………………………………………………
Abdomen …………………………………………………………………
Liver …………………………………………………………………
Spleen …………………………………………………………………
Hernia …………………………………………………………………
External genitalia …………………………………………………………………
Rectal exam. …………………………………………………………………
Vertebrae …………………………………………………………………
Locomotor …………………………………………………………………
Reflexes …………………………………………………………………
Mental health status …………………………………………………………………
 

 

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LABORATORY EXAMINATIONS
Blood Group …………………………   Blood film for malaria …………………………    Hb ………………………… gm%
WBC ………………………… Cells/cu .mm.
Differential PMN ………………………… %   Lymph………………………… %   Mono ………………………… %   Eos ………………………… %
Baso ………………………… %   Band ………………………… %   Blast ………………………… %
Urinalysis : Colour …………………………   Sp. Gr ………………………   pH …………………………   Sugar …………………………
Alb ………………………   Blood …………………………   Ketones …………………………  Blie ……………………………
Micro: WBC ……………………… /HPF.,RBC …………………… /HPF.,Epithelial…………………………… /HPF.
Casts ……………………………… /HPD.,Others ……………………………………………………………………………………

Stool examination for parasite & Ova …………………………………………………………………………………………………………………
Chest X-Ray report ………………………………………………………………………………………………………………………………………………
Urine pregnancy test ……………………………………………………………………………………………………………………………………………
Is the nominee able physically and mentally to carry on intensive study away from home?
……………………………………………………………………………………………………………………………………………………………………………
Is the nominee free from infectious diseases (such as tuberculosis, leprosy, syphilis and filariasis) and other conditions (Such as psychosis and drug addiction) which could present risks for anyone during the fellowship period?
……………………………………………………………………………………………………………………………………………………………………………
Does the nominee have any condition or defect which might require treatment during the fellowship period?
……………………………………………………………………………………………………………………………………………………………………………
Full name and address of
Examining physician (printed)
…………………………………………………………
…………………………………………………………
………………………………………………………… 		Physician signature ………………………………………………… M.D.
(…………………………………………………)
Date ……………………………………………………		  

 

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