Application Form

Please Type or fill-in clearly and send via email or fax prior to 2/09/2010

1. Applicant’s information
First/given name:
Last/family name:
Middle name :
Gender / Nationality
Male / Female
2. Age (in years) (Check one):
20 to 29 / 30 to 39 / 40 to 49 / 50 to 59 / 60 and over

3. Applicant’s contact information

Job title
Organization/Employer
(full name)
Acronym or abbreviation of organization
Organization street address
Postal box address (if relevant)
City
Postal Code
Country
Telephone (office)
Mobile
Fax
Email

4. Higher Education and /or Professional Qualification (in date order / most recent first)

Name of the Institution / Dates / Qualification / Subject / Language of instruction / Result / Date of Completion
Start / Finish

5. English Language Qualifications (Please complete this section only if your first language is not English)

Speaking / Weak / Good / Very Good / Excellent
Writing / Weak / Good / Very Good / Excellent
Listening / Weak / Good / Very Good / Excellent
Reading / Weak / Good / Very Good / Excellent
Overall / Weak / Good / Very Good / Excellent

6. Scope of applicant’s organization (location of people served) (Check one)

International / National / Sub national/Local

7. Type of Organization:for which the applicant works

Ministry of health / Non-Governmental Organization
Governmental Hospital / PrivateHospital
MedicineUniversity Professor / Other , State:------

8. Employment History

Name and Address of Employer (Present First) / Job-Title / Dates
From / To

9. Describe your current responsibilities

10. Howdid you know about this course?

Received an Announcement ( Flyer, Brochure,…etc) via : Email Mail Fax in person
ARADO's Website
RCSI 's Website
A Friend
Other, Specify: ------

11. Describe your reasons for applying for this course, expectations of it, and how it is related to your work.

12. Describe your role as a leader in your organization

13. Describe your greatest personal achievement (this could be outside work)

14. What is your source of funding? (Check all that apply)

Please note that the Royal Collage or ARADO do not offer any financial support or scholarships.

Self-paid / Other sponsor, specify
Employer / Other, specify

15. Passport and nationality information

Do you have a valid passport? We need to know this information to provide visa assistance, if required.

Yes. What is your nationality? Kindly request visa support letter if you need.
No. You must have a valid passport in order to attend this course.
I certify that all information provided is accurate. I understand that this application will be reviewed and applicants will be selected based on relevant experience and space availability. I also understand that if my participation is subject to clearance by my government or to approval by a particular agency in my country, I will comply with this requirement. I also confirm that my English skills are adequate to participate in this English language course.
If selected, I understand that my feedback about the learning activity in which I participate can help the RCSI and ARADO improve its activities in the future. I agree to complete a confidential survey at the end of the learning activity and a few months later if I am asked.
Applicant’s signature: / Date:
Please send this form via fax or email to:
Mr.Tarek Salem El Bakly (CPA,CBM)
Head of Professional Diplomas and Certificates Unit (PDCU)
Arab Administrative Development Organization (ARADO)
Tel: +2-02-22580006 Ext.501
Fax: +2-02-24538917
Email:
Or
Ms.Laila El Sheikh
Coordinating Executive
Professional Diplomas and Certificates Unit (PDCU)
Arab Administrative Development Organization (ARADO)
Tel: +2-02-22580006 Ext.503- Mob:002-018-9534031
Fax: +2-02-24538917
Email:
We will send an acknowledgement that we received your application within two business days of receiving it. If you do not receive an acknowledgement of receipt, please contact us.

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Privacy:RCSI and ARADO will not share your information with any organization beyond the organizers of this learning activity and fellow participants.