ANNEX I
APPLICATION FORM“Seismic Design Criteria for Bridge Structures”
Santiago de Chile, July 23 to August 03, 2018
OFFICIAL APPLICATION(To be signed and confirmed by the maximum authority of the institution)
COUNTRY AND CITY
NAME OF THE INSTITUTION
This organization recommends completing this application in accordance with the regulations of the Kizuna Project "Disaster Risk Reduction Training Program for Latin America and the Caribbean" according to the call and its corresponding general information. If selected, the applicant shall be authorized to travel to Chile on the dates determined by the organizers of the course. Upon his/her return to their country of origin, the organization is committed to provide the necessary support for an adequate application and transfer of the knowledge received and the implementation of the Action Plan.
NameOfficial stamp
Position
Date Signature and stamp of authorizing supervisor
PART A: INSTITUTION INFORMATION
1. Profile of the institution
a) Name of the organization
b) Type of organization (Place an “x” in the corresponding option)
Government
Academic
Private
International
Others*
*If “other”, please indicate:
c) Organization’s mission
d) Connection with international cooperation (Place an “x” in the corresponding option)
Japan Chile Other sources
None
Should there be another modality of cooperation, briefly describe the institution and the main activities:
2. Objective of the application
a) Describe the strategic objectives of your institution linked to the development of public infrastructure in buildings.
b) Briefly describe how the training will support the achievement of the aforementioned objectives.
c) Briefly describe the specific actions that the institution will develop to achieve and/or complement the aforementioned objectives.
d) Briefly describe the reasons why the candidate has been selected, referring to: 1) course requirements, 2) capacity/position or responsibility in the institution, 3) action plans or others.
PART B: APPLICANT’S INFORMATION
1. Personal information. Surname(s)*
Names
Nationality
Date of birth
Sex Male Female
Passport No.
Expiration date of passport
Private address
City
Contact telephone
Contact email**
*Give information exactly as appears in the passport and attach a copy of the passport to this application.**If selected, all the information will be sent to this email. Please give an email that you check constantly.
Person to notify in case of emergency:
Surname(s) Surname (s)
First name(s) Name
Relationship with applicant Relación con el postulante
Private address Dirección particular
Contact telephone Teléfono de contacto
Email Mail de contacto
2. Academic information (University studies and beyond, only. Please attach respective copies of certificates.)
Institution Country PeriodFrom Until
Other courses and trainings (Attach respective copy of certificates and/or accreditations)
Course Institution Country PeriodFrom Until
Have you received scholarships before?
Yes _______ No ________
If “Yes”, please indicate:
Scholarship Country where studies were done
Program taken
Have you been awarded Jica scholarships before?
Yes _______ No ________
Which one(s)? _______________________
Have you fulfilled your obligations as a JICA scholar?______________________________________
PART B: APPLICANT’S INFORMATION
Professional information
1) Current position
2) Description of functions
3) Professional experience
Position* Institution Country PeriodFrom Until
*Briefly describe functions.
4) Self-evaluation on disaster risk reduction.
Describe your experience in two recent projects on disaster risk reduction in which you have participated.
Self-evaluation according to the knowledge you have about the following contents
GRADEOn scale of 1 to 5
1 Seismic Engineering in Buildings
2 Geotechnical Engineering in Buildings
3 Earthquake-resistant analysis in Buildings
4 Land Survey with auscultation equipment for structures
5 Land Survey with auscultation equipment for soils
6 Static laboratory tests of structures
7 Dynamic laboratory tests of structures
8 Constructive Techniques
9 Structural Inspection of Works
10 Building Repair and Rehabilitation Techniques
11 Theoretical and practical concepts of the post-disaster evaluation of buildings (Buildings and Housing)
12 Application in the field of a Standardized Sheet for the Rapid Post-Earthquake Assessment of Buildings and Housing.
13 Formulation and Execution of Action Plans.
AVERAGE
Medical history (If you should have any of the medical conditions listed below, please attach medical certificate). 1. Do you currently take any medication for the treatment of any medical condition? (Give medication
name and dose).
( ) Yes ( ) No
Medication name:______________________ Dose:__________
2. Are you currently pregnant?IMPORTANT NOTE: In the event that a candidate is pregnant and in order to minimize the risk to their health, it is necessary to attach the following documents:
1) Letter of consent to assume economic and physical risks,2) Letter of consent from the participant's supervisor3) Letter from the attending physician, agreeing to your participation in the course.
( ) Yes ( ) No Month of pregnancy:__________
3. Are you allergic to any medication or food?
( ) Yes ( ) No
( ) Medication ( ) Food ( ) Other: ______________
Specify:_____________________________
4. Do you have any of the following health conditions?
High blood pressure( ) Yes ( ) No Observations:________________
Diabetes( ) Yes ( ) No Observations:________________
Respiratory problems( ) Yes ( ) No Observations:________________
Digestive tract problems( ) Yes ( ) No Observations:________________
5.- Other conditions (specify if there is relevant information to be submitted such as food restrictions, allergies, among others).
I hereby certify that I have read the above instructions and have delivered the information requested in good faith. I understand and accept that a pre-existing uninformed medical condition could, under my responsibility, result in the early termination of my participation in the course.
NAME DATE SIGNATURE
DECLARATION(To be signed by applicant)
I hereby declare that I have read the call with all its instructions and corresponding annexes and that the information provided in this form is completely true and includes all the information requested.
Name Date Signature
I hereby declare to have oral and written knowledge of the Spanish language.*(For non-Spanish-speaking countries only)
Name Date Signature
* Attach supporting document such as accreditation test, if available.