Greetings from WIPO Academy

Mister Marcelo Di Pietro, Acting Director of WIPO Academy will be in visit at Queen Mary University on October 18-19, 2010. He would be pleased to meet you on Tuesday 19 October.

Would be it possible to confirm us please.

Training Program –WIPOAcademy

APPLICATION FORM

PHOTO

(do not staple)

Pleasetype or print in block letters and complete as accurately as possible.

A recent passport-size photograph must be attached.

1.Name

1.1Last (Family) name ......

1.2First (Given) name(s) ......

Mr. [ ] / Mrs. [ ] / Miss [ ]

1.3Please complete for visa purposes
Passport No...... Ordinary [ ] Official [ ] Diplomatic [ ]

Date of issue ...... Valid until ......

2.Place and date of birthPlace ...... Year ...... Month ...... Day ......

3.Nationality......

4.Education (Highest Degree(s) awarded)

Name and Place / Year of Study / Subjects / Diplomas
of Institution / from/to

5.Spoken Languages (mother tongue first):

6.Training (list all training courses and fellowships so far awarded, by WIPO, by other United Nations agencies, by intergovernmental organizations, etc.)

6.1General

Name ofthe training institution / Venue and dates / Subjects

6.2Distance Learning Course(s)

Year(s): [ ] [ ] [ ] [ ]

7.Experience in the field of intellectual (Please describe)

......

8.Current Profession

8.1Name of employing Institution:

......

8.2Title of post or position:

......

8.3Date of taking up duties:

......

8.4Description of duties:

......

9.Contact details

9.1Office of the applicant:

Address: ......

......

Telephone number: ......

Fax number: ......

E-mail address: ......

9.2Home of the applicant:

Address: ......

......

Telephone number: ......

Fax number: ...... ......

E-mail address: ......

9.3Name and telephone number of the person to be contacted in case of emergency:

......

Please quote the course to which you apply:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Aims of desired training (describe in particular how the desired training would help you in carrying out your duties):

......

I hereby solemnly declare that to the best of my knowledge and belief all the above statements are true and complete.

Place and date: ...... Signature of applicant: ......

OFFICIAL CERTIFICATE AND RECOMMENDATION

This declaration must be completed and signed by the official national competent authoritysponsoring the applicant.

The undersigned has examined the application from Mr./Mrs./Miss ...... , certifies its truthfulness, and officially recommends that a fellowship be granted to the applicant within the framework of the WIPO Academy Training Program.

Place and date

......

Name of the institution

......

Name of signing official

......

Title of signing official

......

(signature)