ࡱ>  sbjbj)Q)Q 3K;K;sp p \U,9\r ~v9x9x9x9x9x9x9,<W?n9\\99Rv9v9658."6b99096`??888`999?p ; :     With the support of the Government of Flanders, Belgium OceanTeacher Global Academy - OTGA Application Form - 2015 In addition to this completed application form, the following documents are required: CV (Maximum 3 pages) Letter of endorsement (approval for travel to this particular training course) from your employer or supervisor. The endorsement letter must state how your training will further the objectives of capacity development at your institution. Copy of the front page of your passport Part 1 - PERSONAL INFORMATION Surname (family name)Name (given name(s))Gender (male/female)NationalityCountry of residenceBirth date (dd.mm.yyyy)Passport numberPassport date of issue (dd.mm.yyyy)Passport date of expiry (dd.mm.yyyy)E-mail address (main) (e-mail will be the most important method of communication; you must provide one)Alternative e-mail addressPhone number (in case a phone interview is needed) (country code area code number)Nearest airportHome Address (full) Person to be contacted in case of emergency SurnameName (given name(s))Relationship with this personTelephone number (country code area code number)Mobile phone number (country code area code number)E-mail address:  Part 2 - COURSE APPLICATION Course TitleCourse dates (dd.mm.yyyy to dd.mm.yyyy)Venue Motivation to attend this course (up to 300 words) (Personal statement which includes your motivation for attending the course, how it will benefit your professional activity and career development and what it will bring to your institution; furthermore, indicate if there is any particular problem or issue at your institution that attending this training will contribute to solving?)  After completing this training course will you have the necessary resources, including internet connectivity and/or access to necessary software, to apply the knowledge obtained? (Yes/No and explain)  If No, does your institution have, or is it in the process of obtaining, the funding to have the necessary resources, including internet connectivity and/or software, to apply the knowledge obtained? (provide details)  Have you attended other Ocean Teacher Course(s)? (Yes/No)If yes, state which course(s), where and when; also give a short comment on how it contributed to improve your skills (100 words maximum)Are you involved with any NODC/ADU?OBIS node? (Yes/No)If yes, state which and howPlease indicate the link to your profile on the OceanExpert Directory (if applicable) Part 3 - EDUCATIONAL AND PROFESSIONAL BACKGROUND EDUCATION: List your Academic qualifications/degrees, Institution/place(s) and date(s): Academic qualification (Bachelor, Master, PhD, other; also indicate the topic of the degree)Institution /placeDate (Start completion) List any other workshops and training you have attended which are relevant to the course you are applying to (include name, institution/place and dates(s)):  Youll might need to bring your own (or institutional) laptop with you for the training course. Please state if you will have one available for this purpose as well as the brand and operating system. PROFESSIONAL EXPERIENCE: Job Title (current position)Job description/functions (Give a detailed description of your current professional functions and responsibilities: maximum 100 words)Total number of years of professional experience Employer InstitutionAddress of Institution (physical and postal address)Institution telephone number(s)Institution emailName of the Head of InstitutionEmail address of Head of InstitutionDo you have the necessary authorization to take leave from your job to attend the course? (Yes/No) From whom?Would you have any objection if the Ocean Teacher Academy contacted your current employer? (Yes/No)If Yes, explain briefly why (maximum 30 words) Part 4 FINANCIAL RESOURCES Financial assistanceYesNoCommentsPlease indicate whether you can cover any of these expenses. In the case that you have co-sponsorship, please state the source. Travel costs (airfare) Living costs (accommodation and evening meal)Tuition fee (if applicable) Part 5 LANGUAGES The training course will be taught in English. How would you describe your language skills? English (please tick corresponding level): FairGoodExcellentSpokenReadWritten Part 6 DIETARY RESTRICTIONS NoneVegetarian onlyNo porkNo beefOther (please specify) Part 7 HOW DID YOU HEAR ABOUT THIS COURSE? Internet (specify)Announcement by your national IOC/IODE contact points (specify)International Organization (specify)Other (specify) Part 8 DECLARATION BY THE APPLICANT I understand that insurance for travel purposes and my possessions will be covered by myself or my institution. I will investigate any visa requirements for travel on due time, and will take steps to acquire visa(s) in good time. (If your application is successful, a supporting letter may be provided by the host institution of the training course for visa purposes.) I hereby certify that the information provided in this application form is accurate and complete. In case it is requested I will provide proof of any information I provided in this form. I will bring my own (or institutional) laptop for use during the training course. 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