2013 (2013 ITW) Attendee List

2013
Country Attendee Work Position Email

Total Persons

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2013 International Training Workshop for Earth Sciences

National Science and Technology Center for Disaster Reduction, Taiwan, R.O.C. Sponsored by the National Science Council, Taiwan, R. O. C. Instructions: Each applicant should complete this form. Each question must be answered clearly and completely. Detailed answers are required in order to make the most appropriate arrangements. If necessary, additional pages of the same size may be attached. Please attach a photo and send the form back to the NCDR office upon completion via email or by regular mail. I Personal Data
1.Name First name: Middle name: Last name: 2.Gender 3.Date of Birth 4.Nationality 5.Contact Address 6.Email 7.Telephone Number 8.Passport Number: Date of Issue: Place of Issue: Expiration date: 9.Contact person (in case of emergency) Name: Relationship: Contact address and Tel: (yyyy/mm/dd) copy is available. It can also be sent in later Please attach recent photo if an electronic

10.Native Language 11.English Proficiency Ex cel READING Go od Fa ir Ex cel WRITING G oo Fair SPEAKING Exce llent Goo d Fair

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II Present Employment
1.Designation 2.Company/Organizati on 3.Type of business 4.Type of organization Govt. Ministry / Agency Govt./State Owned University / Institute Locally Owned Enterprise Foreign Owned Enterprise Name: Website: Since Month______ Year_____

Joint Venture Others 5.Present Job Duties (Please describe briefly.)

III Education
1. Highest Degree Bachelor Master Doctor degree

Graduated from:

Major:

Professional area:

IV Objectives for participation

Notes: State relevance of this program to your work.

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Items V to VIII are optional. However, we urge you to complete them as the additional information will be helpful in our reviewing work.

V Previous Employment / Job experience

Notes: For each previous employment/job experience, please give designation, organization for which you worked, period of employment, and job duties.

VI Please list your related publications.

VII Please list related research projects which you have participated in the past years (including project titles, introductions...etc.).

VIII Please list International symposiums and conferences which you have attended in the past 5 years (including date, location...etc.).

IX Declaration by Candidate
Please indicate you agree the following declaration:

I hereby declare that the information as provided by me in this document is true and accurate. I understand and accept that any false declaration of information on my part will disqualify me from the program, even while program is in progress. Hereby also undertake to abide by the regulations prescribed by NCDR during the entire period of this program, and to participate fully in it. If I get the admission to the program, I will take a physical examination, including my photo, blood type, heart disease, high blood pressure, malaria, HIV test, and Hepatitis test. I will send a copy of the physical report to NCDR, and bring the physical report to Taiwan. I Agree I Do Not Agree

Signature_______________________
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