Application Form

Personal Details
Surname/Family Name:
Forenames:
Title: Mr/Mrs/Miss/Ms/Dr
Gender: Male / Female / Date of Birth:
Religion (if any):
Postal Address:
Telephone No: / Fax No:
Email Address: (please note that we will use your email address for most correspondence, unless you state otherwise)
Disability/Special needs: (please let us know if you have a disability/special need for which you may require assistance).
Please tell us how you found out about the ACTS course.
Describe your access to a computer, internet and email for use throughout the course.
Language Competence
It is essential that you are able to speak English well enough to participate fully in the course. How do you assess your own ability in spoken and written English, and in understanding others? (please tick)oHpowH
Spoken English / Fluent / Adequate / Weak
Written English / Fluent / Adequate / Weak
Understanding Others / Fluent / Adequate / Weak
Have you ever completed a TOFEL or IELTS tests? The entry required is 6.0 if an IELTS test or on a TOEFL test 550. Kindly fill in the following details
Name of the test ...... Year of the test...... Score received......
Please attach photocopies of your results.
Qualifications
Please detail your academic qualifications since leaving school (High School and Bachelor Degree). Please ensure that you enclose transcripts and/or documentary evidence. Photocopies should be verified by City Hall or Lawyer
Date / Institution / Subjects / Qualification / Class/ Grade
Employment
Please provide brief information about your past employment
Dates / Organisation / Nature of Organisation / Job title and description of work
Please provide information about your current employment.
Date Started:
Organisation:
Nature of the organisation:
Job title / position:
Your duties in the organisation:
Declaration
I hereby confirm that the information contained in this application is correct
Signature:
Date:


Employer’s Statement

To the employer:

The ACTS course has been created to enable individuals and their organisations to strengthen their capacity and competence in the field of conflict transformation and peacebuilding. It uses the student’s own work place as the source of reflection and the basis for their thesis. It is expected that students will write about their own peace, development or human rights work.

During the two-year course participants will be expected to attend six, two weeks residential seminars, and will be carrying out action research related to their work. To ensure participants’ successful completion of the course we envisage that their organisations will need to provide support to them, especially in terms of permitting them time away from their work and permission to write about their reflections insights of their project. Full participation in the residential seminars is compulsory for completion of the ACTS Masters degree. The dates for the seminars are:

Module One Residential Seminar: February 2016 (two weeks)

Module Two Residential Seminar: July 2016 (two weeks)

Module Three Residential Seminar: December 2016 (two weeks)

Module Four Residential Seminar: March 2017 (two weeks)

Module Five Residential Seminar: July 2017 (two weeks)

Module Six Residential Seminar: December 2017 (two weeks)

Statement: I support ______participation in the Applied Conflict Transformation Studies programme and undertake that if he/she is accepted on the course we (their employer) will support them as required.

Signature:

Position:

Organisation:

Contact Telephone Number and Email:

Date:


Course Fees and Finance

Course Fees

The course fee is USD 2500 per year (USD 5000 in total for two years of study).

Students are expected to do their own fundraising. Only a very limited number of ACTS scholarships are available.

Accommodation

Once you are accepted in the course, you will need to attend two-weeks residential workshops for six times in Siem Reap over two years. Further, the ACTS office can assist you in making the necessary bookings according to your preference. Accommodation in Siem Reap costs between USD 12 – 20 per night, depending on the standard you choose.

Some other costs to consider:

Cambodian business visa USD 35 (available on arrival for all)

Departure Tax USD 25

Taxi from airport USD 9

Daily transportation USD 4

Food USD 12 per day

Please fill this form about how you intend to pay for the course:

OPTION 1: If your participation in the course is to be paid for by your employer or another sponsoring agency, please ask a senior representative to fill in this section
Name:
Official Position:
Organisation and Address:
Endorsement: / I undertake that, if the applicant is accepted on the ACTS course, I will arrange for the payment of the full course fee, together with the cost of travelling to and from the course and necessary accommodation. I fully support this application.
Signature:
Date:
OPTION 2: If you plan to pay for the course from your own private resources, please sign your name below.
Signature:
Date:
OPTION 3:Please indicate if you need to raise funds to participate in the course YES / NO
Please explain how you will go about fundraising including whom you will approach for funds.


Statement of Motivation

Please complete a statement of motivation to accompany this application, between 1000 words. This statement should answer ALL of the following questions but should be written as an essay:

1. Why do you want to take part in the ACTS course? What aspects of the course are of particular interest to you?

2. How is the ACTS programme relevant to your current work?

3. What are the difficulties / issues / questions you are dealing with in your work which you would like to explore through this course?

4. What area / topic do you think will be a possible focus for your action research? What has made you interested in this area?

5. The course is challenging. It will require you to think deeply about the work that you do, about your own behaviour and attitudes. How suited do you think you are for this?

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