Mexico Japan Exchange Program for the Strategic Global Partnership APPLICATION FORM
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- Kerry Burns
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1 APPLICATION FORM Please type in capital letters. Do not leave any space blank. Use N/A when applicable. 1. Title of the Training Program: 2. Applicants particulars AFFIX A RECENT PASSPORT-SIZE PHOTOGRAPH HERE Salutation Dr/Mr/Mrs/Ms/Others (please select accordingly) Family Name Given Name Nationality Date of birth Passport Passport Expiry Date Gender Marital status Dietary Religion Restrictions (if any) 3. Home State/Province City/Town Postal Postal Code Tel. No Mobile Primary Secondary 4. Office State/Province City/Town Postal Postal Code Tel. No Fax 5. Person to be notified in case of emergency Name Relationship Contact 6. Beneficiary of Travel Insurance Name Date of birth Relationship Contact 1
2 7. Employment History (starting with present position, i.e. in reverse chronological order) Organization Department Designation Nature of Job From To 8. Educational Record (starting with Higher Education, i.e. in reverse chronological order) Institution Degree obtained Major From To 9. English proficiency Excellent Good Fair Poor Listening Speaking Reading Writing Certificate examples TOEIC: 700 TOEFL PBT: 550 TOEFL IBT: 83 IELTS: 6 Other languages: Excellent Good Poor 10. Profile of Organization Name of Organization Type of Organization National Government Local Government Public Enterprise Private NGO University Other (specify) 11. Present position and current duties Department/Division Present position Date of employment by present Organization Date Month Year Date of assignment to the present position Outline of duties: describe your current duties Date Month Year 2
3 The mission of the Organization and the Department of Division Reason for applicant s selection The post which the applicant will be required to fill upon satisfactory completion of the training Relevance of the course to applicants job 12. Expectation of the applied training program Personal Goal: Describe what you intend to achieve in the applied training program. Relevant experience. Describe your previous vocational experiences which are highly relevant in the themes of the applied training program. of Interest: Describe your subject of particular interest with reference to the contents of the applied training program. 13. Previous Attendance Have you attended any courses sponsored under the Mexico Japan Exchange Program for the Strategic Global Partnership previously? If yes, please state the tittle and date of course(s). Yes/No Date (Year) Course tittle 13. Declaration (to be signed by the Nominee) 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) not to bring or invite any member of my family, (b) to carry out such instructions and abide by such conditions as may be stipulated by both the nominating government and the Mexican Government regarding the program, (c) to follow the program, and abide by the rules of the institution or establishment that implements 3
4 the program, (d) to refrain from engaging in political activity or any form of employment for profit or gain, (e) to return to my home country at the end of the activities in Mexico on the designated flight schedule arranged by the Mexican Institutions, (f) to discontinue the program if the Mexican institution and the applying organization agree on any reason for such discontinuation and not to claim any cost or damage due to the said discontinuation. (g) to consent to waive exercise of my copyright holder s rights for documents or products that are produced during the course of the project, against duplication and/or translation, as long as they are used for the purposes of the program. (h) to observe Mexican laws and ordinances during my stay, if I violate Mexican laws and ordinances, (i) I will return the total amount or a part of the expenditure required for the training depending on the extent of the violation. (j) to approve the following privacy policy: Information Security Policy in relation to Personal Information Protection. a) Mexican Government authorities will properly and safely manage personal information collected through this application form in accordance with its privacy policy and the relevant laws of Mexico concerning protection of personal information and take protection measures to prevent divulgation, loss or damages of such personal information. b) Unless otherwise obtained approval from an applicant itself or there are valid reasons such as disclosure under laws and ordinances, etc. Print name Signature Date Day Month Year 4
5 MEDICAL HISTORY AND EXAMINATION 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 >>> ( ) 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. However, upon the situation, you may be directly inquired by the JICA official in charge for a more detailed account of your condition. 2. Medical History (a) Have you had any significant or serious illness? (If hospitalized, give place & dates.) Past: ( ) No ( ) Yes>>Name of illness ( ), Place & dates ( ) 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 ( ), Place & dates ( ) Present: ( ) No ( ) Yes>>Present Condition ( ) (c) High blood pressure Past: ( ) No ( ) Yes Present: ( ) No ( ) Yes>>Present Condition ( ) mm/hg to ( ) mm/hg (d) Diabetes (sugar in the urine) Past: ( ) No ( ) Yes Present: ( ) Yes>>Present Condition ( ) ( ) No Are you taking any medicine or insulin? ( ) No ( ) Yes (e) Past History: What illness(es) have you had previously? ( ) Stomach and ( ) Liver Disease ( ) Heart Disease ( ) Kidney Disease Intestinal Disorder ( ) Tuberculosis ( ) Asthma ( ) Thyroid Problem ( ) Infectious Disease >>> Specify name of illness ( ) ( ) Other >>> Specify ( ) (e ) Has this disease been cured? ( ) Yes ( ) No (Specify name of illness) Present Condition: ( ) 3. Other: Any restrictions on food and behavior due to health or religious reasons? 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 condition may not be financially compensated by the Mexican Government and may result in termination of the program. Date: Signature: Print Name: 5
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JEFFREY L. DONLEVY, D.D.S., M.D. ABRAHAM ESTESS, D.D.S. SAPNA LOHIYA, D.D.S.
Pharmacy Form Please list the name, phone number, and address of the pharmacy that you would like us to submit your electronic prescription to. Patient Name: Pharmacy Name: Pharmacy Adress and Phone#:
Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)
Worthington Family Dentistry, P.C. 3362 Greystone Way Valdosta, GA 31605 (229) 242-0063 Patient Information Date Name Home Phone Cell Phone (Last) (First) (Initial) Work Phone Other/Fax Sr., Jr., III,
Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge
Spink Dentistry 4005 Crosshaven Drive Birmingham, AL 35243 Phone: 205-967-8555 Fax: 205-968-0202 beth@spinkdentistry.com Spink Dentistry New Patient Questionnaire: Date: Patient Name: Date of Birth: Social
APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation
APM PATIENT INFORMATION Date: / / Name: / / (Last) (First) (MI) Date of Birth / / SS# - - Sex: q Male q Female Address: City State Zip Home Phone # ( ) Work Phone # ( ) Circle preferred number for communication
Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone
Patient Information NameSoc. Sec. # Last Name First Name Middle Initial Address City State _ Zip _ Home Phone _ Cell Phone _ Sex M F Birthdate _ Single Married Widowed Separated Divorced Patient Employed
Welcome to Hawaii Women s Healthcare
Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you
PATIENT INFORMATION. PARENT OR RESPONSIBLE PARTY (if different from patient)
PATIENT INFORMATION Last Name DOB Home Address Home Phone Driver s License # Employer Name Work Address First Name Age Sex Marital Status Cell Phone SSN Email Work Phone Person to contact in case of an
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
SOUTH SHORE NEPHROLOGY, P.C.
SOUTH SHORE NEPHROLOGY, P.C. Please fill out this form along with all the documents included in the patient packet and bring it with you for your upcoming appointment. Be sure to bring your insurance card(s)
Blue Cross and Blue Shield of Illinois Cover Page to the Illinois Standard Health Employee Application for Small Employers
Blue Cross and Blue Shield of Illinois Cover Page to the Illinois Standard Health Employee Application for Small Employers (Groups sized 2-150) The purpose of this document is to help you an employee requesting
PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY)
PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY) Whom can we thank for referring you ( ) Insurance Co. ( ) Advertisement ( ) Our existing patient (provide name) E-mail Cell Phone
Please complete the form below in BLOCK CAPITALS
St Oswald s Hospice Sahara Challenge (3 rd 10 th November 2018) Registration Form Registration Fee: 275 payable upon booking Minimum sponsorship: 2,750 payable to St Oswald s Hospice Please complete this
SHORT-TERM MISSIONS APPLICATION
GENERAL INFORMATION Date Last Name First Name Middle Name Please print your name clearly EXACTLY AS IT APPEARS ON YOUR PASSPORT Present address: City State Zip DOB / / Age Gender: M F Grade Email Home