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Human Rights □ Staff (specify in which field) In Command □ Training □ Other Fields of Expertise Declaration of Nominee: By submitting this “Nomination Form” I confirm that all the information given is correct and complete. I also confirm that I agree to the following conditions of participation: ♦ I am motivated ♦ I accept that the intensive character of the programme does not allow for any additional commitments during the course. ♦ I agree that an assessment of my performance during the course can be made. ♦ I understand that COESPU reserves itself the right to communicate with the Sending State in order to deny admission in case of lack of requisites or that information given in the form proves to be incorrect and result in lack of requisites (i.e. insufficient language skills or lack of active service as a member of the Sending Country’s police force, etc.) or in case of dismissal from the course for any reason. ♦ I authorize the Center of Excellence for Stability Police Units to collect and store my personal details for the purposes related with the course. Submission of the nomination form: The form is to be sent electronically (coespu.info@carabinieri.it) or via fax (00399 0444 932034) to the COESPU in accordance with the memorandum of understanding. Health requirements: Health requirements for the admission to the course are envisioned in a separate document. Place__________________ Date___________________ Signature ________________________________________ NOTE * Nominee is to be younger than 45 year for attendance of Middle Management Course. ** A Carabinieri/Gendarmerie type Force is defined as a Police Force with a military status and organization, either it respond to the Ministry of Defence or to the Ministry of Interiors/Justice, with a general competence in policing. □
ANNEX A UNITED NATIONS MEDICAL STANDARDS FOR PEACEKEEPING AND SPECIAL MISSIONS CONFIDENTIAL ENTRY MEDICAL EXAMINATION UNITED NATIONS AND SPECIALIZED AGENCIES I hereby authorise any of the doctors, hospitals or clinics mentioned in this form to provide the United Nations Medical Service with copies of all my medical records so that the Organisation can take action upon my application for employment. I certify that the statement made by me in answer to the questions below are, to the best of my knowledge, true, complete and correct. I realize that any incorrect or material omission in the medical information form in any other document required by the Organization renders a staff member liable to termination or dismissal. Date: ...................................... Signature: ................................................................................. Pages 1 and 2 are to be completed by the candidate FAMILY NAME (BLOCK CAPITALS) GIVEN NAMES MAIDEN NAME (WOMEN ONLY) SEX: MALE p FEMALE p ADDRESS (STREET, TOWN, DISTRICT OR PROVINCE, COUNTRY) ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... POSITION APPLIED FOR (DESCRIBE NATURE OF WORK) ......................................................................................................... ......................................................................................................... ......................................................................................................... ......................................................................................................... ......................................................................................................... ......................................................................................................... ......................................................................................................... DUTY STATION DATE OF BIRTH NATIONALITY TELEPHONE BIRTHPLACE PRESENT MARITAL STATUS: SINGLE p MARRIED p DATE: ............................. DIVORCED p DATE: ............................. SEPARATED p DATE: ............................. WIDOWED p DATE: ............................. Have you ever undergone a medical examination for the United Nations or one of its agencies? .......................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................... Have you ever been employed by the United Nations or one of its agencies? .................................................................................................................................................. If so, please state when, where and for which Organisation? .......................................................................................................................................................................................................................................................................... Relative Age (if still alive) State of health (If still alive, present state; if deceased, cause of death) Age at death Have members of your family had the following illness or disorders? Father High Blood Pressure Mother Heart Disease Brothers Diabetes Sisters Tuberculosis Spouse Asthma Children Cancer TO BE COMPLETED BY THE OFFICIAL REQUESTING THE MEDICAL EXAMINATION Name of Official: ........................................................................................................ Department or Unit: ................................................................................................... Date: .......................................................................................................................... VERY IMPORTANT : Please indicate the recruiting Agency or Organization Epilepsy Mental Diseases Paralysis MS-2 FORM Yes No Who? TO BE COMPLETED BY THE OFFICIAL REQUESTING THE MEDICAL EXAMINATION Medical Classification : p p p p 1a 1b 2a 2b Comments: ................................................................................................................ ................................................................................................................................... ................................................................................................................................... Signature: .......................................................... Date:.............................................. 42 Selection Standards and Training Guidelines for United Nations Civilian Police (UNCIVPOL)
Page 1 and 2: Fax/Most Urgent/Out at Once From :
Page 3 and 4: 12 th High Level course List-I Sr N
Page 5 and 6: CENTRE OF EXCELLENCE FOR STABILITY
Page 7: PROFESSIONAL DOMESTIC EXPERIENCE (S
Page 11 and 12: ANNEX A UNITED NATIONS MEDICAL STAN
Page 13 and 14: FORM FC-2 [See rule 3(b)] Applicati

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