Courses on Sustainable Agriculture

Application Form

Course on food and nutrition security and HIV/AIDS A regional refresher course for alumni from Southern and Eastern Africa

Lusaka, Zambia, April 17-30, 2005 Closing date for application: March 1, 2005 Code: 80/09 Personal Details Last Name: Title: First name: Middle Name:

Gender: Male Female Civil Status Single Married Date of birth: / /

Address for correspondence: Street: No: Town: Zip Code: State: Country:

Telephone: Fax: E-mail:

Academic Record Field of Study Educational Institution & Location Qualification From To

Other relevant training:

Computer Skills: Word Excel Access Other:

Employment Details Name of Organization: Department: Contact Person:

Your present position: From

Address: Street: No: Town: Zip Code: State: Country:

Telephone: Fax: E-mail:

Type of Organisation: Government/Public NGO Private

Application Form

English Language Proficiency Excellent Good Fair Mother Language used in higher Tongue: education:

Candidates from non-English speaking countries should attach a certificate of English proficiency, issued by a recognized language institute

Work experience (Please attach C.V. if more information is relevant) Description of your work:

Previous Work Experience (related to the subject of the course) From To

Total number of years working experience (relevant or irrelevant to the years course):

What is the practical use of this course for

Earlier participation in training at IAC I participated in the course on: , in (year) My participation in this course was funded by: Netherlands Fellowship Programme Other donor: I did not participate/graduate in a course at IAC, but my colleague participated in the course on: in (year): Name of colleague:

I certify that I have answered the above questions truthfully, Date: / / Town:

Signature of candidate: This application is supported by my superior Name superior: Signature of superior: Position:

Please attach your CV and your letter of motivation.

To be returned to: International Agricultural Centre P.O. Box 88, 6700 AB Wageningen, The Netherlands fax: +31 (0)317 495 395 e-mail: [email protected]