GADJAH MADA UNIVERSITY REGIONAL TRAINING CENTER FOR HEALTH RESEARCH SUPPORTED BY WHO-TDR Course Application Form 2 nd Batch of Regional Course on Good Clinical Practice - GCP ( August 17 – 19, 2016) Application Deadline: Sponsorship: June 17, 2016, Normal: July 17, 2016 1. APPLICANT INFORMATION (2-3 persons per institution) COUNTRY : Apply for (please thick) : Sponsorship Early Bird Registration Normal Registration (Please fill in the name exactly as it is in applicant passport) Personal Information – Applicant 1 Title: Prof/Dr/Ms/Mr. Family Name First Name (s) (as in passport) Organization Office Address Postal Code/ City Country Fax Telephone number including country code Home Address Postal Code/ City Country Email address Passport number Date of birth Place of birth Page 1 of 5
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GADJAH MADA UNIVERSITY REGIONAL TRAINING CENTER FOR HEALTH RESEARCH SUPPORTED BY WHO-TDR
Course Application Form2nd Batch of Regional Course on Good Clinical Practice - GCP (August 17 – 19, 2016)
Application Deadline: Sponsorship: June 17, 2016, Normal: July 17, 2016
1. APPLICANT INFORMATION (2-3 persons per institution)
COUNTRY :Apply for (please thick) : Sponsorship
Early Bird Registration Normal Registration
(Please fill in the name exactly as it is in applicant passport)
Personal Information – Applicant 1Title: Prof/Dr/Ms/Mr.Family Name
First Name (s) (as in passport)Organization
Office AddressPostal Code/ CityCountryFax
Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address
Passport numberDate of birthPlace of birth (city, country)Present job title
Job description
Knowledge of English Written: Average___ Good___ Excellent ___Spoken: Average___ Good___ Excellent ___
Computer literacy Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____Internet: Proficient___ Need Help___ Never Used____
Page 1 of 3
Personal Information – Applicant 2Title: Prof/Dr/Ms/Mr.Family Name
First Name (s) (as in passport)Organization
Office AddressPostal Code/ CityCountryFax
Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address
Passport numberDate of birthPlace of birth (city, country)Present job title
Job description
Knowledge of English Written: Average___ Good___ Excellent ___Spoken: Average___ Good___ Excellent ___
Computer literacy Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____Internet: Proficient___ Need Help___ Never Used____
Personal Information – Applicant 3Title: Prof/Dr/Ms/Mr.Family Name
First Name (s) (as in passport)Organization
Office AddressPostal Code/ CityCountryFax
Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address
Page 2 of 3
Passport numberDate of birthPlace of birth (city, country)Present job title
Job description
Knowledge of English Written: Average___ Good___ Excellent ___Spoken: Average___ Good___ Excellent ___
Computer literacy Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____Internet: Proficient___ Need Help___ Never Used____
2. SPONSORSHIP
WHO-TDR through the course organizer offers full scholarship for 7 participants of SEAR countries which covers course materials, faculty fees, lodging (not applicable for residence of Yogyakarta/GMU staff), lunch and coffee breaks during the course, as well as travel expenses (economic airfare) from country of home institution.
3. REGISTRATION This 2nd Batch of Regional GCP Course is designed as a 3 day intensive program with a maximum of 25 participants. Registration open : 1st April – 17th July 2016 Course fee per person :
a. Sponsorship : April 1 – June 17, 2016 : FREE (please see 3. sponsorship)b. Early Bird : April 1 –July 5, 2016 : Rp. 4,000,000,- (US$ 320) *c. Normal : July 5 – 17, 2016 : Rp. 5,000,000,- (US$ 400) *
*) ticket, accommodation and lumpsum are not includedAttach the following to this application form (can be downloaded in http://retrac.fk.ugm.ac.id): The participants’ typewritten detailed Curriculum Vitae Motivation letter A scanned or copy of participants’ passport (international participants) Recommendation letter from head of institution. Send the application package by the deadline (Sponsorship: June 17, 2016, Normal: July 17, 2016) by fax, e-mail or post to:
Centre for Tropical Medicine, Faculty of Medicine, UGM 2nd Floor Gedung PAU - UGM, Jl. Teknika Utara, Barek, Yogyakarta 55281, Indonesia, Tel: (+62274) 547147 Fax: (+62274) 547147Contact Person: dr. Ktut Rentyasti Palupi, MPH (Email: [email protected])
Failure to provide all of the information requested may result in the rejection of your application.
