Information Security Training Sponsorship Programme

Application Form
Name
E-mail
Mailing Address

Country
Telephone / Fax
Employer
Job Designation
Working Experience (Please attach your resume)
Please indicate preferred course

Name of Referee
Designation
Department
Telephone / Fax
E-mail
Relationship

Courses

Network Security Administrator (E|NSA)

Certified Ethical Hacker (C|EH)
Computer Hacking Forensic Investigator (C|HFI)
Certified Security Analyst (E|CSA)
Certified Disaster Recovery Professional (E|DRP)
Licensed Penetration Tester (L|PT)
Important Notes:
Criteria for Sponsorship

Sponsorship applicant must be an IMPACT member

Trained candidate trained must attempt for certification within 6 months from end of
training class and within 12 months from activation of self-study classes
Requesting organisation and sponsored candidate will provide testimonies and work
with EC-Council on various public relations activities (where the need arises)
Organisations and candidates will allow EC-Council to share certification details of the
candidates to EC-Council or IMPACT / IMPACTs Global Response Centre

Declaration by Applicant:

I hereby declare that:

1. All the information given in this Application Form and all the documents submitted are
complete, true and correct. I authorise the EC-Council or IMPACT to verify the
information from whatsoever sources and by whatever means that EC-Council or
IMPACT deems appropriate.
2. I understand that EC-Council or IMPACT reserves the right to forfeit my eligibility for the
Scholarship or revoke
3. Any Scholarship approval granted to me or recall any Scholarship granted to me in the
event that:
a) any of the information, statement or fact disclosed in this Application Form is
false or incorrect; or
b) if there is any misrepresentation of information, statement or fact in this
Application Form; or
c) if any of the documents submitted in support of this application is falsified or
forged.
4. I do not have any criminal record.
5. I understand and accept that EC-Council or IMPACT reserves the right and has the
absolute discretion to approve or reject my application without assigning any reason
whatsoever and I accept all decisions by EC-Council or IMPACT as final and conclusive.
6. EC-Council or IMPACT shall not be held responsible for any loss or delay in respect to
this application

Signature of Applicant

...........................................................
Date:

Please email completed application form and supporting documents to: training@impact-
alliance.org

IMPACT
Jalan IMPACT
63000 Cyberjaya, Malaysia

Tel: +60 (3) 8313 2036

Fax: +60 (3) 8319 2020
Contact Person: Kelinah Mina Paul www.impact-alliance.org
 Information Security Training Sponsorship Programme

Letter of Recommendation

(DATE)

Manager, Training & Skills Development

International Multilateral Partnership Against Cyber Threats (IMPACT)
Jalan IMPACT
63000 Cyberjaya
Selangor Darul Ehsan
Malaysia.

Dear Sir,

Re: Recommendation for Information Security Training Sponsorship Programme

With reference to the Information Security Training Sponsorship Programme, we would like to
endorse our support and recommend the following person from our country to participate in this
program:

Name of Applicant:

Address:

Contact details.:

Yours faithfully,

Name of Referee:

Designation: