African Governance Institute

Candidate Form for the Capacity Building Session on “Strengthening Citizens’ Participation for Domestic Accountability in Africa”

Theme of the Training Program:Domestic Resource Mobilization

October 8-12, 2012

  1. Personal Information

Family Name:
…………………………………………… / Name:
…………………………………………… / Other names:
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Date of birth: Day ____ Month ____ Year ____ / Place of birth:
………………………………………….
Nationality: ______Sex (Please tick off): M. F.
Personal Address:
……………………………………………………………………………………………………………………………………………………………………………………………………………… / Email: ______
Tel: ______Mobile: ______
Fax: ______
Official Address (where to contact you):
……………………………………………………………………………………………………………………………………………………………………………………………………………… / Email: ______
Tel: ______Mobile: ______
Fax: ______
Emergency Contact / Tel: ______
Mobile: ______
Full Name:
……………………………………………………………………………………………………………………………………………… / Address:
………………………………………………………………………………………………………………………………………………
  1. University Education

Name and place of study:
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…………………………………………………... / Years of Study
From_____To_____
From____ To_____
From____ To_____ / Major Courses
______
______
______/ Diploma Received ______
______
______
  1. Languages

Languages / Excellent / Advanced / Intermediate
English
French
  1. Trainings

Training Institution
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……………………………………………………. / Date
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  1. Employment:

a)Current Position: ______
Years of Emp:______From______
To______
Name Address of employer
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…………………………………………………………………… / Description of the Post:
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b)Previous Position: ______
Years of Emp: ______From______
To ______
Name Address of employer
……………………………………………………………………
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…………………………………………………………………… / Description of the Post:
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  1. Have you answered AGI questionnaire onEnhancing citizen voice and accountability in Africa?

Yes No

If you answered "No", Please complete the survey.

  1. Summarize your motivations for this program along with any other previous experience you have had in dialogue and political advocacy for accountability in Africa (not more than one page or 250 words).


  1. Personal Commitment:
  1. I certify that the answers to the above questions are complete and correct and that I am in good health to travel and participate in the program throughout the period.
  1. If I am selected to participate in this program, I will:
  • Conduct myself properly as a trainee and comply with all the rules and procedures of AGI;
  • Completely devote my time to the training program;
  • Participate in all the work, activities and events organized as part of the program;
  • Refrain from any political, commercial or other activity incompatible with the training program;
  • Stay with the group in the same hotel as the AGI has reserved for the group;
  • Return to my country at the end of the training program.

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LocationDate

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Candidate Signature

  1. Confirmation by the authority nominating the candidate:

- Name of authority: ______

- Official Title: ______

- Tel.: ______Email: ______

Signature and Seal of the Authority

……………………………………………………

IMPORTANT1:

1

This application form and CV, and for non-ECOWAS nationals, photocopies of essential pages of your passport must arrive by mail or fax to the African Governance Institutebefore September 15, 2012 at the following address:

African Governance Institute (AGI)

Tel.: (221) 30102 94 88

Fax: (221) 33824 67 06

Web Site:

Email: