WORLD CONGRESS FELLOWSHIP PROGRAMME

Please note:

1)Occupational safety and health (OSH) professionals and personnel in the field of OSH from developing countries are eligible to apply. Applicants who have submitted abstracts for the World Congress 2017 are preferred.

2)Application form must be filled up in English.

3)Email completed Application Form with required documents to

WORLD CONGRESS FELLOWSHIP PROGRAMME APPLICATION FORM

Applicant Personal Details
Title:
First Name: / Last Name:
Date of Birth: / Age: 25 - 30 31 - 40 41 - 50
51 - 60 > 60
(Please tick appropriate option.)
Gender: Male Female
(Please tick appropriate option.) / Citizenship:
Passport No.:
(Please attach a copy of your passport to this form.)
Residential Address
Street Name/ Number:
City:
Country: / Postal code:
Phone (with country code): / Email address:
Current Employment/ Education Information
Name of Company/ Organisation/ School:
Designation: / Country:
Type of Organisation:
(Please tick appropriate option.)
Organisation in field of OSH
Government, Ministry, Authority
School, University, Institute of Higher
Education
Trade & Industry
International Organisation
Others:
______/ Job Type:
(Please tick appropriate option.)
Workplace/ OSH Professionals
Occupational Physicians
Government Officials
Academia
Labour Inspectors and Safety and Health
Inspectors
Officials/ Representatives from
International and Regional Organisations
Employer Representatives
Trade Unions and Workers
Representatives
Instructors, Trainers and Teachers in
the field of OSH
Media Representatives and Journalists
Communication and Public Relations
Manufacturers and Importers of
OSH Products and Services
Human Resource Professionals
Others:
______
Abstract Submission
Have you submitted an abstract for the XXI World Congress on Safety and Health at Work 2017?
Yes No
If yes, please provide Abstract’s reference number(s) : ______
Have you been notified that your abstract(s) has been selected by the XXI World Congress on Safety and Health at Work 2017 organising committee?
Yes No
If yes, please indicate selection type:
Oral Presenters Poster Presenters
Type of Fellowship
Are you seeking for Full or Partial Fellowship?
Full Fellowship Partial Fellowship
If Partial Fellowship, please indicate area needing assistance:
Travel air ticket to Singapore Accommodation in Singapore
Please complete the sections below.
In less than 200 words, describe your work, experiences or achievements in the field of OSH in your country.
In less than 200 words, tell us your aspirations in improving OSH issues in your country.
In less than 200 words, tell us why attending the XXI World Congress on Safety and Health at Work 2017 is important to you. How would you apply the knowledge gained at the Congress in your work, studies and communities?
Declaration
I hereby declare that the particulars stated above are true and correct to the best of my belief and knowledge, and that I have not wilfully supressed any material fact. I understand and agree that any misrepresentation or omission of facts in my application will justify denial and cancellation of joining the Fellowship Programme.
Applicant’s signature: ______Date: ______