Application Form

High Performance Computing Tools for Computational Science 2015

01- 05 December 2015, Bandung, Indonesia

Part I (to be completed by applicant)

  1. Personal Detail

Female Male / Recent Photograph
From Applicant
First Name
Last Name
Nationality
Home Addres
Email
Telephone / Fax
International Airport
(nearest to residence)
  1. Employment Data

Institution Name
Official Address
Telephone/Fax
Email
Position
Description of Work
C. Relevance of the Workshop
Relevancy of the workshop to current job / responsibility / profession
Description
D. Medical Statement
Based on the qualified medical doctor examination (please attach), I am in good health, free from infectious diseases and able physically and mentally to carry out any relevant duties away from home
E. Declaration
I certify that the statement in this application form is true and correct to the best of my belief. If my participation in the workshop is accepted, I undertake to: a) follow such instructions and abide by such condition as may be be stipulated by both the nominating government, host Government. b) Cooperate to achieve the purpose of this workshop and abide by the rules and regulations made by the organizers. c) Stay out of political activities and any form of employment for profit or gain. d) Return to my home country as soon as the workshop finishes. I also fully understand that even during the workshop I might be subsequently withdrawn from it by full authority of the host Government if I fail to make collaboration in the workshop or I conduct inappropriate as a participant of the workshop
Date: Full Name:
(signature of applicant)

Part II (to be completed by the nominating organization)

A. Language Certificate
Relevancy of the workshop to current job / responsibility / profession
Description / Read Write Listen Speak
Good Good Good Good

Average Average Average Average

Poor Poor Poor Poor
B. Financial Support (only for foreign participants)
If financial support from the organizers is needed please mark the appropriate bullets
Travel Allowance Accommodation Daily Allowance
or
Self Funding (does not need any financial support from the organizer)
C. Government Statement
The nominating Government gives the following assurances:
a) All information supplied in this form is complete and correct;
b) Should the candidate's language qualification prove to be insufficient or should the candidate's state of health not correspond to the examining physician's statement, the nominating Government will accept the responsibility for the consequences and any costs arising therefrom;
c) It is noted that the sponsoring organization(s), host country(ies) and host institution(s) do not accept liability for the payment of any costs or compensation arising from damage to or loss of personal property, or from illness, injury, disability or death of a participant while he/she is traveling to and from or attending the workshop, and it, the nominating Government, undertakes the responsibility for such coverage;
d) The position of the candidate will be retained for him/her and he/she will continue to receive during the workshop a salary and related emoluments to enable him/her to meet his/her financial commitments in his/her home country;
e) If accepted, the nominee will conduct himself/herself in a manner compatible with his/her status as a participant and will refrain from engaging in any political and commercial activities.
Date:
Full Name:
Title/position:
(signature)
Medical Certificate
First Name / Last Name
Address:
Age: Gender: ( Female / Male )
Height: cm Weight: kg
Medical Report
ATTENTION : Please Describe Specifically.
1 / Describe candidate’s present health condition.
2 / Does the candidate show any PHYSICAL deficiences that would limit his/her performance?
Yes No
If yes, please explain.
3 / Does the candidate show any MENTAL deficiences that would limit his/her performance?
Yes No
If yes, please explain.
4 / Does the candidate have a history of illness or disorders that would limit his/her
Ability to research conduct researches?
Yes No
If yes, please explain.
5 / List any infectious diseases that the candidate might be carrying.
6 / Describe any present condition or illness that would require the candidate to seek
Medical treatment while participation in the research program.
I hereby certify that the above statements are true and correct.
Date: ......
Signature:......
Physician:
Clinic:
Address: