The Ministry of Gender Equality & Family, Republic of Korea
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1 The Ministry of Gender Equality & Family, Republic of Korea Attach Recent Photograph Here (approx 3x4cm) NAME CANDIDATE S BIODATA (Please Type or Print) A. PERSONAL DATA Number: NATIONALITY PRESENT POSITION NAME OF COMPANY/ ORGANIZATION ADDRESS OF THE COMPANY/ ORGANIZATION TYPE OF BUSINESS TYPE OF ORGANIZATION (Please type your name as indicated in your passport. Underline surname / family name. Include Chinese character, if any) URL: Address: DATE OF BIRTH Yr: M: D: Passport SINCE WHEN DATE JOINED Date and Place of Issue: Expiry Date: Tel: Fax: Manufacturing Finance IT Government Others TOTAL NO. OF EMPLOYEES Govt ministry/ University/ In case of Locally owned Agency Institutions Private company: Joint Venture Govt/ State/ Local govt NGO/ Owned Enterprise Association Foreign Owned HOME ADDRESS OF THE CANDIDATE CONTACT PERSON IN CASE OF EMERGENCY DIETARY RESTRICTION Address: Hand Phone: Tel: Fax: Name: Relationship: Address: Tel: Fax: If any, please specify: (Kindly be informed that this bio-data form must be submitted and processed through Korean Ministry of Gender Equality & Family by the respective APEC member economy. Forms, sent directly to the Korean Ministry of Gender Equality & Family Secretariat would be neither processed nor acknowledged. A soft copy of the form could be downloaded from the website at PBF-M
2 B. ACADEMIC QUALIFICATION University/Institution (Bachelor and post graduate only) Major Field of Study Cert. /Diploma/Degree Year C. TRAINING/ SEMINAR (Last 5 years only) University/ Institute/ Org. Major Field of Training/Seminar Year D. PARTICIPATION IN OTHER APEC PROJECTS (Last 5 Years only) YES NO If yes, please specify below PROJECT DATES YEAR
3 E. PRESENT JOB DUTIES/ACTIVITIES State your present job duties and other activities in consultancy, training, research and publication relevant to the project. Please attach organization chart, and highlight your position. F. PREVIOUS EMPLOYMENT / JOB EXPERIENCE (Last Five Years) For each previous employment / job experience, please give designation, organization worked for, period of employment, and job duties.
4 G. OBJECTIVE FOR PARTICIPATION Kindly refer to Project Notification, and state relevancy of project to your work, and indicate your expectation (s) from the project.
5 H. DECLARATION BY CANDIDATE I hereby declare that I have read and understood the Project Notification for this project. I further declare that the information as provided by me in this document is true and accurate. I understand and accept that any false declaration of information on my part will disqualify me from the project, even when it is in progress. I hereby also undertake to abide by the regulations prescribed by the Korean MOGEF, the host country(ies), and the implementing organization(s) during the entire period of this project, and to participate fully in it. Signature: Date: Name: I. CONFIRMATION OF CANDIDATE S ENGLISH LANGUAGE PROFICIENCY (To be filled by Director/Alternate Director/Liaison Officer) The candidate s English Language proficiency has been evaluated as follows:- As fluent as the candidate s native language. Competent to participate in discussion and express himself. Proficient enough to follow lectures/discussions, but will have difficulties in expressing ideas and giving comments. I further certify that the candidate belongs to: Profit-making organization Non-profit making organization Signature: Name: Designation: Date: ASIA-PACIFIC Economic Cooperation Central Government Complex, 55 Sejong-ro (77-6 Sejong-ro 1ga), Jongro-gu, Seoul, Korea ( ) TEL : (82) FAX : (82) kcb32@mogef.go.kr
6 The Ministry of Gender Equality & Family, Republic of Korea International Relations Division, MOGEF, Central Government Complex, 55 Sejong-ro, Jongro-gu, Seoul, Korea ( ) TEL: FAX : URL : MEDICAL AND INSURANCE DECLARATION FORM Only for Applicant without any of the Health Conditions listed on the Reverse Side 1. NAME (last name, first name, middle name) 2. DATE OF BIRTH 3. NATIONALITY 4. PROJECT TITLE (VENUE) I hereby declare that : a. I have read carefully the Project Notification of the above project and declare that I have the physical and mental fitness to attend the project; b. I have had no health conditions listed on the reverse side during the last 5 years and am free from any ailment likely to impair the health of others or affect my participation in the project; c. I shall secure the required comprehensive travel insurance as specified in the Project Notification of the above Project; d. I understand that neither Korean Ministry nor the implementing organization shall be liable for any medical or other costs incurred during the project, except for those specifically stated in the Project Notification; and e. I shall bring with me the necessary medicines for minor illness as prescribed by my physician since they may not be readily available at the venue of the above project. I affirm this declaration on medical and insurance requirements of the project as specified in the Project Notification. Date Applicant s Signature
7 MEDICAL AND INSURANCE CERTIFICATION FORM Only for Applicant having any of the Health Conditions stated under item. 6 below 1. NAME (Last name, first name, middle name) 2. DATE OF BIRTH 3. NATIONALITY 4. PROJECT TITLE (VENUE) 5. Please indicate Yes or No if you had ever had any of the following during the YES NO last 5 years : a. Tuberculosis, asthma, emphysema, or other lung illnesses b. High blood pressure, heart by-pass, heart attack or other heart diseases c. Stomach ulcer, liver (hepatitis), gall bladder disease d. Kidney problem, stone or blood in urine e. Diabetes, sugar or glucose in blood or urine f. Depression, attempted suicide, or other psychological symptoms g. Tumor, abnormal growth, cyst or cancer h. Bleeding disorder, blood disease (sickle cell anemia) i. Malaria, Cholera, small pox or epidemic disease j. Allergy k. Other serious illnesses (Please specify) I certify that the above information is true and correct to the best of my knowledge. I understand that neither Korean Ministry nor the implementing organization shall be liable for any physical or mental problem that I may develop during my participation in the project and that I shall be responsible for bringing with me necessary medicines as prescribed by my physician since they may not be available at the venue of the project. Further, I understand that I shall have to secure the required comprehensive travel insurance as specified in the project Notification of the above Project. Date Applicant s Signature TO BE COMPLETED BY A MEDICAL DOCTOR Based on above given information, I have examined the above applicant and certify that he/she is free from any ailment likely to impair the health of others and fit to participate in the project referred to in this form. Hospital/Clinic s Name : Examiner s Name & Title : Examiner s Signature : Date : Remarks, if any :
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To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits Beginning January 1, 2011 Medicare began covering an Annual Wellness Visit in addition to the one-time Welcome to Medicare
FLEXI HEALTH PLAN INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN APPLICATION FORM
FLEXI HEALTH PLAN INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN APPLICATION FORM Please use BLOCK letters to complete this form. Proposal form once accepted, becomes part of the policy document. Member Information
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU
ADVANCED FOOT CARE SPECIALISTS, P.C. 240 W. PASSAIC STREET, SUITE 4 * MAYWOOD, NEW JERSEY 07607 * TEL: 201-880-6000 FAX # 201-880-5999 PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: DATE
PATIENT REGISTRATION FORM Account #:
PATIENT REGISTRATION FORM Account #: All forms must be completed and signed prior to treatment. GENERAL INFORMATION Patient Name: First Middle Last Address: Home Phone No: Work Phone No: Cell Phone No:
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
AUBURN URGENT CARE. Patient Information. Name: Last First Middle. Permanent Address: Apt #: Zip: City: State: Employer: Phone: ( )
AUBURN URGENT CARE Patient Information Name: Last First Middle Date of Birth: / / Social Security: Permanent Address: Apt #: Zip: City: State: Race: Gender: M F Undifferentiated Home Phone: ( ) Cell:(
CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET
CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET DATE: TIME: DR: PATIENT INFO: PRIMARY CARE DOCTOR: REFERRING: NAM E: First Middle Last SEX: AGE: DOB: SS# RACE: ETHNICITY: Hispanic Non Hispanic
PERSONAL INFORMATION
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# ADDRESS:
PATIENT INFORMATION LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# EMAIL ADDRESS: OCCUPATION: EMPLOYER: RACE: ETHNICITY: White
Application for Short Term Missions Team
Team Destination: *Please fill out one application per family. All completed application forms and deposits must be turned in to: Global Ministries 446 W 40th St Holland, MI 49423 Legal Name Required (Make
METHODOLOGIES. The course will be conducted through: Indiviual Assignment. This course will be fully conducted in English. Candidates should :
METHODOLOGIES INTERNATIONAL CERTIFICATE COURSE IN PROPERTY VALUATION REAL ESTATE PRACTISE This programme is offered by the parent department i.e. the Department of Valuation and Property Services, Ministry