On Emergency Response to Cultural Heritage at Risk

On Emergency Response to Cultural Heritage at Risk

Regional Training Course

on Emergency Response to Cultural Heritage at Risk

ERCH 2018

APPLICATION FORM

Please complete this form in full, by computer.

  1. APPLICANT

FirstName: / Family Name: / Photograph
Middle Name: (if applicable)
Date of Birth:mm/dd/yyyy / Age:
Nationality: / Place of Birth:
Expertise:
Cultural Heritage Field
First Aid / Emergency
Response to Disaster Risk
or Related Field / Gender:
Male
Female
Nearest Bus Terminal(for travel to Tirana, Albania)
Terminal Name: City: Country:
Please listany food you cannot eat(due to allergy problem or religious reasons)
  1. PROFESSIONAL DETAILS

Present Occupation (Function title)
Organization, Institution, or Company
Department (if applicable)
Address (Street, number, State/province, Country)
Personal Email Address
Organizational and/or departmental website (if available)
Personal telephone number
(incl. country code) / Organization’s telephone number
(incl. country code)
Name and function title of your direct supervisor / Email address of your direct supervisor:
Please describe your professional activities and main responsibilities (max 150 words):
  1. PROFESSIONAL EXPERIENCE

Less than 2 years experience in the cultural heritage conservation or disaster risk management field

2 to 5 years experience in the cultural heritage conservation or disaster risk management field

5-15 years experience in the cultural heritage conservation or disaster risk management field

More than 15 years experience in the cultural heritage conservation or disaster risk management field

Please list all previous professional activities that are relevant for the Course.

Activity / Organization / Description
  1. EDUCATIONAL BACKGROUND

Academic Qualifications

Full Name of Institution
and Country / College, Department / Duration
(from - to) / Degree Obtained

Relevant Professional Courses

Full Name of Course, Institution and Country / Duration (from - to) / Certification Obtained
  1. PUBLICATIONS AND RESEARCHS

List your significant publications (title, publisher and date) and/or research projects

Title / Publisher / Date
  1. ENGLISH LANGUAGE ABILITY

Please rate your language proficiency from Excellent to Poor - Put ( X ) in the related box

Excellent / Good / Fair / Poor
Spoken
Understanding
Written
  1. PERSONAL STATEMENT

Explain why you are applying for this course, what you hope to learn from it, and how it will benefit your professionaldevelopment and your institution. (max 500 words)

  1. The Cultural Heritage Site/Historic Building that shall be presented as a personal case study in the framework of Emergency Response topic of the course

Name of the site/monument and location:

Is this a World Heritage Site?

Yes No

If not, what is the status of the site/museum?

Tentative List of World Heritage Nationally Protected Site

Locally Protected Site Unprotected Site

What is the type of cultural heritage selected by you?

Single Monument Group of Buildings or Ensemble

Historic City or Urban Area Archaeological Site Cultural Landscape

Museum Other (please specify)

Photo /s of the site/monument

  1. Reason for Selecting the above Cultural Heritage Site / Historic Building:
  1. Where did you learn about this training course?

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