APPLICATION FORM Please type or write clearly in capital letters. Do not leave anyspace blank. Use “NIL” or “N/A” where applicable.
Course Title: Course Date: Course Venue
Linking Cities to Finance 22 October 2015 Jakarta, Indonesia
Photo of Applicant
Applicant's Particulars Salutation Family Name Given Name Nationality
Dr/Mr/Mrs/Ms/Others (please specify)
Date of Birth (dd/mm/yy) Passport Expiry Date
Passport Number
(dd/mm/yy)
Airport of Departure to Jakarta Date of Arrival in Jakarta
Gender Current Job Title Participation in AsiaPacific Urban Forum
Yes
No (If yes, you are expected to arrive on 18 October 2015)
Office Address Country Postal Address (Street, House/Block, Unit, etc)
State/Province
City/Town
Postal Code Country Code
Area Code
Country Code
Number
Tel No.
Area Code
Number
Fax No. Secondary Email
Primary Email Person to contact in case of emergency
Relations
Employment History (starting with present position, i.e. in reverse chronological order) Organisation
Department
Designation
Nature of Job
From
To
(dd/mm/yy)
(dd/mm/yy)
PRESENT
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Educational Qualifications (starting with highest qualification attained, i.e. in reverse chronological order) Educational Qualification Attained
Educational Institution
From
To
(dd/mm/yy)
(dd/mm/yy)
Previous Attendance Have you previously attended any events sponsored by CDIA and/or UCLG ASPAC? If yes, please state the name and date of course(s) 1. 2.
Yes/No
City Projects Does your city have specific infrastructure projects that need to be linked to finance? Please enumerate and provide details.
Proficiency in the English Language Excellent
Good
Fair
Basic
Spoken Written
Relevance of the training course to your job
Source of Funds for Travel Costs [Pls. tick appropriate box/boxes.]
□ My city / office □ From national government □ Private Sponsor Page 2
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□ Personal Money □ Requesting for organisers to subsidise on:
□ 2 nights accommodation in Jakarta
□ Economy Return Airfare from My City □ Visa Fees ________________________________ Date
_____________________________________________ Signature of applicant
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