/

SHORT COURSE

ON

Family Planning and Reproductive Health
January 12 – 24, 2009

IIPS, Mumbai, India

/
Bill and Melinda Gates Institute for Population and Reproductive Health

APPLICATION FORM

(Please type or use block letters.)

Female

Male

Name: ______

(FIRST) (MIDDLE) (LAST)

Occupation: ______Job Title: ______

Home Address: ______

Office Address: ______

Work Phone: ______Home Phone: ______Fax: ______

Area Code/Number Area Code/Number Area Code/Number

Primary E-mail: ______Secondary E-mail: ______

Country of Citizenship: ______Country of Legal Residence: ______

Indicate preferred mailing address: Home Office

Date of birth ______

(month) (day) (year)

Educational Background: Begin with most recent university/college

Dates / Institution attended / Major subject / Degree completed

Occupational Experiences: Give Three Most Recent, starting with Current Position

Dates / Institution attended / Major subject / Degree completed


APPLICATION FORM (CONTINUED)

Relevant work experience: Begin with most recent employment, and include all current job (Attach additional information on a separate page if necessary)

Dates / Position/title / Employer / City/Country

Describe your present duties and responsibilities, with specific emphasis on proposed short-term course (if any):

______

______

______

List your important publications, particularly in field relevant to the course. (if any)

Title of publication / Date, where published

Please describe below:

a.  Learning objectives for taking the course

______

______

______

b.  Expectations for applying the skills

______

______

______

c.  Future areas of family planning research in which you are interested in pursuing after the course

______

______

______

d.  Willingness to be contacted after the course: YES NO

IIPS AFFILIATION (check all that apply)

Alumnus Employee Attended Continuing Education Course

Are you currently enrolled in a degree program at the IIPS? Yes No

If Yes, which course? ______

Are you currently enrolled in a degree program in another university Yes No

If Yes, which course? ______

Who is sponsoring you to attend the course (Please tick the appropriate box):

Getting the sponsorship from:

Name of the Institution /Organization /Person: ______

Full Address: ______

______

Office Phone:______Fax______E-mail:______

Seeking support from IIPS

Important:

1.  Participants wishing to receive an IIPS/JHSPH-Gates Institute Course Certificate are expected to complete a post-training two-hour written competency examination. This examination will be composed of multiple-choice and short-answer questions based on course materials. A passing score of 70 points is required. Other participants will receive a letter of course participation.

2.  One reference must be submitted in support of your application if you are seeking support from IIPS. The referee should address the usefulness of the course to the institution/applicant and be received no later than November 28, 2008. The selected candidates would be notified by December 19, 2008.

Date ______Signature of applicant ______

Completed applications should be received by November 28, 2008.
Send the completed Application Forms directly to:
Usha Ram, Ph.D.
Reader & Course Coordinator
Department of Public Health and Mortality Studies
International Institute for Population Sciences,
Govandi Station Road, Deonar, Mumbai - 400 088. India
Tel: (91) 22-25563254/5/6 ext. 127
Fax: (91) 22-25563257; E-mail: