International Consultants' Training Course - GHDonline

Annex III: Application form to participate in the course
Application Form
Please fax or email this form along the professional profile form
No later than 15 January 2007
Our direct fax number: +31-70-358 4004 (attn. Ms Orlanda Graca, GracaO@kncvtbc.nl)
Name Participant:
Address:
Tel.: _____
Email:
Fax:
For visa purposes:
Nationality: _______________
Passport number:____________
Date of birth: ________________
The organizing committee will review the applications and select the most
suitable candidates by 31 January 2008. Once participants are selected,
KNCV Tuberculosis Foundation will send a confirmation note and assist
with travel arrangements. Based on the flight schedule, room reservation
will be confirmed.
Please indicate the exact title and full name as you would like to appear on
your certificate of attendance:
____________________________________________
Please indicate if you have any special diet: Yes/No
If yes please define: _______________
Signature
Date:
25