/ Institutional Development for Energy in Afghanistan(IDEA)
YES –Youth Entrepreneurship Support /
YES –Youth EntrepreneurshipSupport
Renewable Energy and Energy Efficiency

November 2017

APPLICATION FORM
Part A: Information about the Nominee
NOTE: it is required to fill in the designated * items as is shown below.

1)University*

2) National ID Number: (Tazkira Number)*

3)Information about the Nominee*

3.1) Name of Nominee

Last Name*

First Name*

Middle Name (if any)

To which training of the YES program are you applying*please select only one

Renewable Energy Energy Efficiency

3.2) Nationality / Afghan -National / 3.4) Date of Birth*
3.3) Sex* / Male / Female / DD / MM / YY / Age

3.5) Educational*

University
Department/Division
Semester and Year / Semester, Year
Date of Enrollment / DD / MM / YY / Expected Date of Graduation / DD / MM / YY

3.6) Type of University*

Public / Private

3.7) Please describe your current responsibilities and daily rituals*(120 words)

3.8) Contact Information*

Office / Address:
TEL: / Mobile:
FAX: / E-mail:
Home / Address:
TEL: / Mobile (Cell Phone):
FAX: / E-mail:
Contact person in emergency / Name:
Relationship:
Address:
TEL: / Mobile:
FAX: / E-mail:

3.9) Language Proficiency*

Language to be used in the program / English
Listening / Excellent / Good / Fair / Poor
Speaking / Excellent / Good / Fair / Poor
Reading / Excellent / Good / Fair / Poor
Writing / Excellent / Good / Fair / Poor
Certificate (Examples: TOEFL, IELTS and etc.)
Native Language
Other languages / Excellent / Good / Fair / Poor

3.10) Educational Record*

Institution / City/
Country / Period / Degree obtained / Major
From
Month/Year / To
Month/Year

3.11) Trainings

Institution / City/
Country / Period / Field of Study / Program Title
From
Month/Year / To
Month/Year

3.12) Career Record* (if any)

Organization / City/
Country / Period / Position or Title
From
Month/Year / To
Month/Year
4) Future Plans or Personal Goal: Please state what you intend to achieve in the Youth Entrepreneurship Support Program?
150 words

5)Declaration (to be signed by the Nominee)*

Please sign and attach the scan copy of this document along with your application

I certify that the statements I made in this form are true and correct to the best of my knowledge.

If accepted for the program, I agree:

(a)To follow the program, and abide by the rules of the institution or establishment that implements the program,

(b)To refrain from engaging in political activity or any form that may harm the regulations of German Cooperation and Afghanistan Gov.

(c)To share the knowledge and skills I have received in a Pass it On (PiO) exercise at the end of the program,

(d)To be present in all the classes and workshops during the training period on time and according to the schedule developed by the training provider,

(e)To develop a business plan as instructed and moderated by the coach and meet the entire deadlines for preparation, presentations and assignments,

Date / Name
Signature
MEDICAL HISTORY AND CONDITION
Please fill this form (hand written) and attach the scan copy along with your application.

1)Present Status*

(a)Do you currently use any drugs for the treatment of a medical condition? (Give name & dosage.)

No /  Yes. Name of Medication ( ), Quantity ( )

(b)Are you pregnant?

No / Yes ( months )

(c)Are you allergic to any medication or food?

No / Yes / If yes, please indicate bellow:
Medication
Food
Other

(d)Please indicate any needs arising from disabilities that might necessitate additional support or facilities.

( )
Note: Disability does not lead to exclusion of persons with disability from the program.

2)Medical History*

(a)Have you had any significant or serious illness? (If hospitalized, give place & dates.)

Past / No / Yes, Name of illness ( )
Present / No / Yes, Present Condition ( )

(b)Have you ever been a patient in a mental hospital or been treated by a psychiatrist?

Past / No / Yes, Name of illness ( )
Present / No / Yes, Present Condition ( )

(c)High blood pressure

Past / No / Yes
Present / No / Yes, Present Condition ( )

(d)Diabetes (sugar in the urine)

Past /  No / Yes
Present /  No / Yes, Present Condition ( )
Are you taking any medicine or insulin? / No / Yes

(e)Past History: What illness (es) have you had previously?

Stomach and Intestinal Disorder / Liver Disease / Heart Disease / Kidney Disease
Tuberculosis / Asthma / Thyroid Problem
Infectious Disease | please specify name of illness ( )
Other | Please specify ( )

Hereby, I certify that I have read the above instructions and answered all questions truthfully and completely to the best of my knowledge.

I understand and accept that medical conditions resulting from an undisclosed pre-existing, existing or future condition may not be financially compensated by GIZ-IDEA and may result in termination from the program.

Date / Name
Signature

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