The Law of the Sea (Unclos) and Its Related Instruments In

TRAINING PROGRAMME ON REGIONAL OCEAN GOVERNANCE FRAMEWORK, IMPLEMENTATION OF THE UNITED NATIONS CONVENTION ON

THE LAW OF THE SEA (UNCLOS) AND ITS RELATED INSTRUMENTS IN

THE SOUTHEAST ASIAN & THE INDIAN OCEAN

Phuket, Thailand

February 28-March 19, 2016

Participant Nomination Form

To be completed by a senior official of the nominating Government department/national or regional organization.

The Government/organization

nominates

as a candidate to attend

and certifies that:

(a)all information supplied by the nominee in the attached form is complete and correct;

(b)the nominee has adequate knowledge, appropriately tested, of the English language;

(c) the absence of the nominee during his/her attendance at the course would not have any

adverse effect on his/her status, seniority, salary, pension or similar rights; and,

(d) if selected, the applicant would conduct at least one seminar/workshop after the course

to share the knowledge and skills gained from the training.

On return from attendance at the course, it is proposed to employ the candidate as follows:

Title of candidate’s proposed post:

Proposed duties and responsibilities:

Name of nominatorSignature of nominator

Title of nominator Date

Postal address Official seal:

E-mail address

______

Application

Instructions

The application form is to be completed in English by the candidate. Please type or write clearly using block capitals. Each question must be answered, as complete and detailed informationis required for the most appropriate selection of candidates. If necessary, additional pages of the same size may be attached. A functioning e-mail address is imperative to ensure timely communication, and applications cannot be considered without one.

1. Title (Mr/Ms/Dr) Given Name(s) Family Name (Surname)

2. Date of Birth: DayMonthYear

3. Office Postal Address Courier Address (include street name & no.)Home Postal Address

4. Contact numbers Country Area Number Hours

code code

Fax (please include hours of operation): ……………………………………………………………………………..

Work telephone (please include working hours): ……………………………………………………………………

Home and/or mobile telephone: …………………………………………………………………………….

E-mail address(es): ………………………………………………………………………………………….

5. Name, address, telephone & fax numbers of person to be notified in case of emergency

6. Passport No. Country of Issue Date of IssueExpiry Date

Do you have an additional passport? Yes / No (circle one) If Yes, state country of issue:

7. Languages (indicate level of proficiency in reading, writing and speaking)

Read Write Speak

Mother Tongue (specify):

English:

Other(s) (specify):

Please describe your practical experience in spoken English (e.g. occasionally have conversations with visitors, use English regularly at work, attended English-language university)

Have you ever taken a TOEFL/IELTS? Yes / No (circle one)

If Yes, state the test name, score and date:

Please note that telephone interviews may be conducted to assess the candidate’s English capabilities.

8. Post-secondary Education and Training (Start with most recent and work backwards)

Name of InstitutionDates of StudyQualification/Degree & Subject

(e.g. B.Sc. in Marine Biology)

9. Scholarship(s) you have previously held

10. IOI Training Programme(s) you have previously attended

11. Employment Record

(i) Title of current/most recent position:

Years of service (from - to):

Name and postal address of employer/organization:

Name and e-mail address of supervisor:

Detailed description of your work:

If selected, will you be returning to this position after the course? Yes / No (circle one)

If No, please clarify:

(ii) Title of previous position of most relevance:

Years of service (from - to):

Name and postal address of employer/organization:

Name and e-mail address of supervisor:

Detailed description of your work:

12. Membership in professional societies and activities in civil, public or international affairs of relevance

13. Relevant publications you have written (do not attach)

14. Organizations or funding agencies applied to for scholarships (attach copies of correspondence). Please note that IOI scholarships are intended for those who can demonstrate they have attempted to find external funding.

15. Detailed description of the practical use you will make of this training on your return home, in relation to the responsibilities you expect to assume and the conditions existing in your country in your field of work. Please also include a brief outline of how you would share the knowledge and skills gained during the programme through at least one seminar or workshop on your return, and who/how many people would benefit from this. (Use extra page if you require additional space.)

16. Proposed course of attendance

___February 28- March 19, 2016

17. Where/how did you hear about the IOI training programme?

18. I certify that my statements in answer to the foregoing questions are true, complete and correct to

the best of my knowledge

Signature of Candidate Date

Contact Address:

Marine and Coastal Resources Research and Development Institute

(Att: IOI Regional Ocean Governance Training in Phuket, THAILAND)

Department of Marine and Coastal Resources

120 Mu 3, 6TH Floor, Ratthaprasasanaphakdee Bld.

The Government Complex

Chaeng Wattana Rd., Tungsonghong, Laksi, Bangkok 10210, THAILAND

Email:

Mobile: 097-9899100, 093-9502257

______

All nominees should complete application form and return to IOI Thailand () as soon as possible but no later than 30 November 2015

Successful applicants will be notified of their acceptance by 15 December 2015

Medical Report

Instructions

To be completed by a registered medical practitioner after thorough clinical and/or laboratory examination. The IOI reserves the right to require the candidate to undergo a further medical examination before his/her course participation.

Name of CandidateDate of BirthMale/Female

Is the person examined at present in good health and enjoying full working capacity?

Is the person examined able, physically and mentally, to carry on intensive study abroad?

Does the person examined have any infectious or other diseases (for example, tuberculosis, trachoma, malaria, AIDS) which could present risks for the candidate and/or his/her contacts during the course? If so, please provide details.

Does the person examined have any conditions (including but not limited to pregnancy) or any allergies which might require treatment during the course? If so, please provide details. It is important to note that the medical insurance does NOT cover pre-existing conditions, and the participant would find medical care extremely expensive in Thailand.

Name and Address of Examining Physician:

______

______

______

Signature of Examining Physician Date