APPLICATION FORM by L3Yaq6O

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									           Global Human Rights Leadership Training Institute (GHRLTI)
                                           2010 APPLICATION FORM
                                        DISTANCE EDUCATION COURSE

 Certificate Course on “Project Development & Management from a Gender Perspective”
                                       14th November – 9th December 2011

Please Type or Print Legibly in Ink
                               COURSE TITLE AND PROPOSED DATE


                                            PERSONAL DETAILS
Last Name(s):                                    First Name(s):


Gender: [ ] Male      [ ] Female                    Marital Status: [ ] Single      [ ] Married
Postal Address:


Physical Address (if different from above):


Telephone (plus country and local code):            Skype ID (If any):

Mobile/Cell Phone:                                  Personal E-mail Address:

Date of Birth:                                      Country of Residence:

                                          EMPLOYMENT DETAILS
Employer’s Name:


Address:


Telephone (plus country and local code)             E-mail Address:

Brief outline your responsibilities:


                                            COURSE HISTORY
Have you participated in any of our training courses before? If yes, indicate the course title:




                                  ENGLISH LANGUAGE ABILITY
Please indicate below your knowledge (excellent, good, fair, or poor) of the English Language
             Reading                              Writing                              Speaking
                                       COURSE RELATED COSTS
(Please tick an X the appropriate box in the space below if you are able to support yourself in full or part in
terms of the costs of the course.)

Yes, I can pay for the cost [ ]                     No, I require partial scholarship [ ]


                                        PROFESSIONAL GOALS
Please write a statement of not more than 200 words, explaining why you wish to participate in this training
and how the training will help you achieve your goals.


                                             MOTIVATION
What do you expect to gain from your participation in the course?



                                               PARTICIPATION
Directory of Participants
The directory of participants is an invaluable tool for making contacts and networking during and after the
program. It includes the contact information and a short biographical note for each participant, facilitator and
resource person and for their organisation. The list is distributed to all participants at the end of the program.

Would you like to be included in this directory?             [ ] Yes      [ ] No

                                       PERSONAL INFORMATION
Please print clearly the email address you will be using for the course:

Do you have access to Internet?      [ ] Yes       [ ] No

Please return this form duly completed together with the following documents:
     One passport photo (This will be posted on the course website) [ ]
     Curriculum Vitae (Maximum of two pages) [ ]

                                                 The Candidate
By signature below, I certify that to the best of my knowledge, the information provided in all parts of my
application is accurate and complete.

Signature:                                                             Date:

The deadline for submission of application is 9th November 2011.
Please email the completed application to: applications@justicegroup.org


GHRLTI
Human Rights and Justice Group Int’l
Nigeria: 53, Western Ave., Ojuelegba, P.O.Box 3326, Surulere, 101014, Lagos, Nigeria
         Tel: +234-8034923400 | Fax: 206-984-20707
U.S.A.: 1208 Massachusetts Ave., Suite 4, 2nd Floor, Cambridge, MA 02138
         E-mail: info@justicegroup.org |Website: http://www.justicegroup.us

								
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