ANNEX I

APPLICATION FORM
DIPLOMA IN SEISMOLOGY
Santiago de Chile, June-July 2018
Disaster Risk Reduction Training Program for Latin America and the Caribbean –
KIZUNA

OFFCIAL APPLICATION
(To be signed and confirmed by the institution’s maximum authority)

COUNTRY

NAME OF INSTITUTION TO WHICH THE APPLICANT BELONGS

This organization recommends completing this application in accordance with the regulations of the
Disaster Risk Reduction Training Program for Latin America and the Caribbean - KIZUNA according
to the call and its corresponding general information. If selected, the applicant shall be authorized to
travel to Chile on the dates determined by the course executors. Upon his/her return, the
organization is committed to provide the necessary support for the adequate application and
transfer of the knowledge received.

Name
Official stamp
Position

Email

Date Signature
PART A: INFORMATION ABOUT THE INSTITUTION

1. Institution’s profile

a) Name of the organization

b) Type of organization
(Place an “x” on the corresponding option)

Governmen Academi Privat Internationa Other*

t c e l

*If the answer is “other”, please indicate:

c) Organization’s mission

d) Link with international cooperation

(Place an “x” on the corresponding option)

Japan Chile Other None

sources

If there is any other form of cooperation, briefly describe its main activities:
 2. Objective of the application

a) Describe the strategic objectives of the institution related to the COURSE’S TOPIC.

b) Briefly describe how the training will support the aforementioned objectives.

c) Describe briefly the concrete actions that the institution will develop to achieve
and/or complement the aforementioned objectives.

d) d) Briefly describe the reasons why the candidate has been selected, referring to:
1) course requirements, 2) capacity/position or responsibility in the institution, 3)
action plans or others.1

1 In case of presenting more than one candidate, indicate the order of priority in the entry of the
documentation to the scholarship platform.
PART B: APPLICANT’S INFORMATION

1. Personal Information.

Surname(s)*

First name(s)

Nationality

Date of birth

Sex Male Female

Passport No.

Passport expiration date

Private address

City

Contact telephone

Email**

*Give information exactly as appears in the passport.

**If selected, all the information shall be sent to this email. Please give an email that you check constantly.

Person to notify in case of emergency:

Surname(s)

First name(s)

Relationship with applicant

Private address

Contact telephone

Email
 2. Academic Information.
(University studies and beyond only)

Degree obtained Institution Country Period

From To

Other courses and trainings

Course Institution Country Period

From To
Have you received scholarships before?

Yes _______ No ________

If “Yes”, please indicate:

Scholarship Country where studies were Program taken

carried out

3. Professional information

1) Current position

2) Description of functions

3) Professional experience

Position* Institution Country Period

(list from most recent to the oldest From To
according to academic activity)

*Briefly describe functions

PART C: MEDICAL HISTORY

(If you should have any of the medical conditions listed below, present medical certificate).

1. Do you currently take any medication for the treatment of any medical condition? (Give
medication name and dosage).
Medication name:______________________ Dose:__________

2. Are you currently pregnant?

IMPORTANT NOTE: In the event that a candidate is pregnant and in order to minimize
the risk to their health, it is necessary to attach the following documents:

1) Letter of consent to assume economic and physical risks,

2) Letter of consent from the participant's supervisor
3) Letter from the attending physician, agreeing to your participation in the course.
( ) Yes ( ) No Month of pregnancy:__________

3. Are you allergic to any medication or food?

( ) Yes ( ) No

( ) Medications ( ) Foods ( ) Others: ______________

Specify:_____________________________

4. Do you have any of the following health conditions?:

 High blood pressure ( ) Yes ( ) No Observations:________________

 Diabetes ( ) Yes ( ) No Observations:________________

 Respiratory problems ( ) Yes ( ) No Observations:________________

 Digestive tract ( ) Yes ( ) No Observations:________________

problems
5.- Other conditions (specify if there is relevant information to be submitted such as food
restrictions, allergies, among others).

I hereby certify that I have read the above instructions and have faithfully delivered the information
requested. I understand and accept that a pre-existing medical condition not informed could, under
my responsibility, result in the early termination of my participation in the course.
NAME DATE SIGNATURE
DECLARATION
(To be signed by applicant)

I hereby declare that I have read the call with all its instructions and corresponding
attachments and that the information provided in this form is completely true and
corresponds to all the information requested.

Name Date Firma

I hereby declare to have oral and written knowledge of the Spanish language.*
(For non-Spanish-speaking countries only)

Name Date Firma

* Attach supporting document such as accreditation test if available.