APPLICATION FORM – C³MC

(to be sent, duly filled in, to

Scuola Superiore Sant’Anna

Prof. Andrea de GUTTRY

Piazza Martiri della Libertà, 33

56127 PISA, Italy

e-mail: )

SECTION 1 – APPLICANT INSTITUTION’S OFFICIAL DATA
1.1 Name and Legal Status
Name and acronym of institution in the original language
Name of institution in English (formal translation)
Date, place and number of authorisation (registration) / Date: Place: / Number:
Legal status
1.2 Full contact address
Street Address:
City / Postcode / Country and region
Postal Address:
(If different from street address)
City / Postcode / Country and region
Telephone: / Fax:
Email: / Web site:
1.3 Main contact person
Name:
Position:
Street Address:
City / Postcode / Country and region
Postal Address:
(If different from street address)
City / Postcode / Country and region
Telephone: / Fax:
Email: / Website: / http://www.
SECTION 2: OPERATIONAL CAPACITY AND EXPERTISE
2.1 Present your institution briefly (goals/activities):
2.2 How long has your institution been in operation?
2.3 Describe the training courses you delivered during the last 3 years (maximum 500 words)
2.4 List of ENTRI-related courses offered[1] [provide details of each course in annex form 1]
Basic/Core courses on Peace operations:
Ø 
Ø 
Ø 
Ø  / Specialisation Courses:
Ø 
Ø 
Ø 
Ø 

SECTION 3: MOTIVATION

3.1 Give reasons for request of C³MC certification
3.2 State type of certification requested [tick as appropriate]
C³MC-Label
Renewal of Label / Current Expiration Date: / / /200
3.3 Select training Courses for which certification is requested [tick as appropriate and provide details of each course selected in Annex Form 2]
Basic/Core Courses on:
□  Peace Operations
□  Country-Specific Pre-Deployment Course / Specialisation Courses on:
□  Media Development
□  New Media: Tools & Techniques for Civilian Crisis Management
□  Child Protection, Monitoring Rehabilitation
□  Press Public Information
□  Mission Management, Administration Support
□  Human Rights
□  Leadership & Gender
□  Security Sector Reform
□  Good Governance & Civil Administration
□  Conflict Analysis & Conflict Sensitivity
□  Mentoring in Civilian Crisis Management
□  Hostile Environment Awareness Training (HEAT)
□  Gender Advisers
□  Rule of Law
□  Negotiation & Mediation
SECTION 4- Declaration
I, the undersigned and designated representative of the applicant institution, request the Certification of its courses and the possibility to use the C³MC-Label. To this extent
I hereby certify that the institution:
Has the professional competence specified in the application,
Understands that application for certification may involve one or more visits of inspection by authorised assessors with or without prior notice,
Undertakes to cooperate fully with the assessors during their visits, and will supply all document requested by the authorised assessors,
Agrees that, if awarded, will use the C³MC label according to the terms foreseen in the gentlemen agreement t and for specified duration.
4.1 Signature
Date and place / Signature and stamp
Name of signatory / Position

SECTION 5 - Enclosures

Please enclose the following documents
5.1 Documents:
□  Annex 1: List of Previous courses offered
□  Annex 2: Description of Courses for certification
□  Statute of applicant
□  Agenda of course for which certification is requested

OFFICE USE ONLY

Date Received and signature of receiver: ______

Date Copy sent to Program Administrator: ______

Date Forwarded to Panel for Action: ______

PANEL’S FINAL DECISION:

□  Full Approval

□  Conditional Approval

□  Renewal Approval

□  Adding New Course

Duration of accreditation: ______Valid Until: ______

Date, signature and stamp

- 6 -

ANNEX 1: DETAILS OF PREVIOUS RELATED COURSE OFFERED

COURSE INFORMATION (Continued)
Please answer as fully as possible for each session/module of the course.
COURSE TITLE:
DURATION: / DATES: / VENUE:
TARGET TRAINEES (please list by title e.g. Civil, military Personnel)
CERTIFICATE: Did participants receive any form of certificate at the end of the course? (if yes, state type)
Title of each session/module / Duration of teaching (hours) / Learning objectives
(3-5) for each session / Content outline / Teaching and Learning methods / Language (s) / Methods of assessing attendees / Name of Resource Person

ANNEX 2: DETAILS OF COURSE (S) FOR WHICH CERTIFICATION IS NEEDED

COURSE INFORMATION
Please answer as fully as possible for each session/module of the course.
COURSE TITLE:
DURATION: / DATES: / VENUE:
TARGET TRAINEES (please list by title e.g. Civil, military Personnel)
CERTIFICATE: Will participants receive any form of certificate at the end of the course? (if yes, state type)
Title of each session/module / Duration of teaching (hours) / Learning objectives
(3-5) for each session / Content outline / Teaching and Learning methods / Language (s) / Methods of Learning
and assessment / Name of Resource Person

[1] The complete list of ENTRI curricula and the related concepts are available at: http://www.entriforccm.eu