5-Day Capacity Building Training Programme on
“Water Audit and Rainwater Harvesting”
November 29th – 3rd December 2016- Nairobi, Kenya - Supported by MEA, GOI

(Application for the Training Programmefunded by the Ministry of ExternalAffairs,

Government of lndia)

(Please read instructions carefully before applying)

  1. PERSONAL PARTICULARS

Name:
Surname:
Sex (tick one): / MALE/FEMALE
Marital Status: / Date of Birth:
  • Passport Details

Name on Passport / Nationality
Passport no: / Date of Issue:
Place of Issue: / Valid till:
  • Details of Stay

Office / Home
Address:
Tel Nos.
Mobile/Cell:
Fax:
Email:
Special dietary needs, if any:
  • Person(s) to be notified in case of Emergency

Official Contact / Personal/Family Contact
Name:
Address:
Tel Nos.
Mobile/Cell:
Fax:
Email:
  • Educational Qualification(s)

Degree / Diploma / Certificates / Year / Name of Educational institute
1.
2.
3.
4.
  • Professional Qualification(s), if any:

Degree / Diploma / Certificates / Year / Name of Educational institute
1.
2.
3.
4.
  1. Details of Employment/Profession (Current & Previous)

Name of Employer/Company / Position / Period
1.
2.
3.
4.
Are you an employee of: (mark appropriate box)
  1. Government b. Industry c. Institution/University
d. Consultancy e. Service f. Other (Pl. Specify)______
  • Details of Present Employer

Name: / Telephone no:
Address:
Email:
Describe your current work indicating your responsibility:
  1. Have you ever attended a course sponsored by the Government of India? YES NO

If Yes, details of the course:
  1. Details of Course(s) attended, if any, outside your country

Country / Course Details & Duration / Year / Sponsor/Programme
  1. Please describe in your own words (about 100 words):
(a)qualification/experience in the related programme applied for; and
(b)reason(s) for applying for this training programme
  1. Certification of English language proficiency (by Employer/Nominating Organization)

Good / Basic / Remarks
Spoken
Written
Mother tongue/ Native language:
Other language(s), if any:
This is to Certify that the Applicant has a Good Knowledge in Working English.
Name:
Address:
Telephone no:
Email:
Signature with Date:
MEDICAL REPORT
(To be certified by a doctor/hospital on the panel of the Indian Mission, UN Mission, if any or as designated by Indian Mission)
i)Name of Applicant:
ii)Age:
iii)Sex (Male/Female):
iv)Height (cm):
v)Weight (kg):
vi)Blood Group:
Blood Pressure:
i)Name of Applicant:
  1. Is the person examined in good health at present?
/ YES/NO
  1. Is the person examined physically and mentally to carry out intensive training away from home?
/ YES/NO
  1. ls the person free of infectious diseases (HlV/AIDS, tuberculosis, trachoma, skin diseases, etc), Yellow Fever certificate (in case of peoplecoming from that region or as laid out in WHO regulations)?
/ YES/NO
  1. Does the person examined have any medical condition or defect which might require treatment during the course?
/ YES/NO
  1. List of any observed abnormalities indicated in the Chest X-ray

I certify that the applicant is medically fit to undertake a training programme in Kenya
Name of Doctor/Physician:
Registration no:
Address of Clinic/Hospital:
City/Town:
Telephone:
Email:
Date:
Signature of Doctor/Physician / Seal of Clinic/Hospital
IMPORTANT NOTICE
  • Please read the form carefully. The applicalion will be automatically rejected if any column is inaccurate, incomplete or blank.

  • Declaration by the candidate and the recommendations from employer (Form A), are compulsory pre-requisites.

  • Working knowledge of the english language is a pre-requisite.

  • Candidate who leave the course midway for personal reasons without prior permission of the Ministry of External Affairs or remain absent from the programme without sufficient reasons are expected to refund the cost of training and airfare to Government of lndia.

UNDERTAKING BY THE APPLICANT
I, ______(Name, Middle name ,
Family Name) of country______certify that information provided by me in this form is true, complete and correct.
I also certify that:
(i)I have read the course brochure and that I am aware of the course contents and living conditions in Kenya.
(ii)I have sufficient knowledge of English to participate in the training programme.
(iii)I am medically fit to participate in the Course and have submitted a medical certificatefrom the designated doctor.
(iv)I understand and accept that any false declaration of information on my part will disqualify me from undertaking the programme.
(v)I have not applied for or am not required to attend any other training course/conference/meeting, etc, during the period of the programme applied for.
If accepted for the Training Programme, I undertake to:
(a)Comply with the instructions and abide by Rules, Regulations and Guidelines as may be stipulated by both the nominating and sponsoring Governments in respect of the training;
(b)Follow the full and complete course of training and abide by the Rules of the Establishment in which I undergo training;
(c)Return to my home country at the end of the training;
Date:
Place: (SIGNATURE OF THE APPLICANT)
Name: ______

Form A

Letter of recommendation

5-Day Capacity Building Training Programme on ‘Water Audit and Rainwater Harvesting’ Organized by FICCI and supported by Ministry of External Affairs (MEA), GOI

(November 29th – 3rd December 2016, Nairobi, Kenya)

byCompany

Date:______

Name(s) of Nominee: ______

______

From: (Name of Company)

______

Address: ______

______

Name of President / Chairman/Head: ______

Signature: ______

(TEL: )

(FAX: )

We admit that the person indicated in the attached Form(s) has enough language level and meet the age for attending the Programme. We also recognize that the person has suitable ability and careers. Therefore, we recommend the person(s) as participant(s) for the Programme.

Note: Kindly send the duly filled in Application Form via email to Karishma Bist, Joint Director, FICCI ( ) or Sugandha Arora, Assistant Director, FICCI ()

The last date for receiving nominations is October 7, 2016.