<p> Application Form </p><p>Course on food and nutrition security and HIV/AIDS A regional refresher course for alumni from Southern and Eastern Africa</p><p>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: </p><p>Gender: Male Female Civil Status Single Married Date of birth: / / </p><p>Address for correspondence: Street: No: Town: Zip Code: State: Country: </p><p>Telephone: Fax: E-mail: </p><p>Academic Record Field of Study Educational Institution & Location Qualification From To</p><p>Other relevant training:</p><p>Computer Skills: Word Excel Access Other: </p><p>Employment Details Name of Organization: Department: Contact Person: </p><p>Your present position: From </p><p>Address: Street: No: Town: Zip Code: State: Country: </p><p>Telephone: Fax: E-mail: </p><p>Type of Organisation: Government/Public NGO Private</p><p>Application Form </p><p>English Language Proficiency Excellent Good Fair Mother Language used in higher Tongue: education: </p><p>Candidates from non-English speaking countries should attach a certificate of English proficiency, issued by a recognized language institute</p><p>Work experience (Please attach C.V. if more information is relevant) Description of your work:</p><p>Previous Work Experience (related to the subject of the course) From To</p><p>Total number of years working experience (relevant or irrelevant to the years course):</p><p>What is the practical use of this course for </p><p>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: </p><p>I certify that I have answered the above questions truthfully, Date: / / Town: </p><p>Signature of candidate: This application is supported by my superior Name superior: Signature of superior: Position: </p><p>Please attach your CV and your letter of motivation.</p><p>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]</p>