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APPLICATION FORM FOR KOICA TRAINING 

Korea International Cooperation Agency
HQ: 128 Yungun-dong, Chongro-ku, Seoul, Korea 110-782
     Tel: 822-740-5114 Fax: 822-744-1092 http://www.koica.go.kr     
ICTC : 304-3 Yumgok-dong, Seocho-ku, Seoul, Korea 137-170
     Tel: 822-3460-6114 Fax: 822-571-4593 E-mail: training@koica.go.kr
Ⅰ. TITLE OF COURSE : 
	
Ⅱ. PERSONAL DATA
 Full Name:                                                                 
                    First                    Middle                   Last (Surname)	
Date of Birth	Sex	Marital Status	Nationality	Religion	
Month	Day	Year					
			□M    □F				
Passport Number		Airport of Departure		

 Home Address :                                                               
 Tel No :          -         -            Fax No :          -         -          
           country code     area code         number                     country code     area code       number
Mobile No :         -         -          E-mail Address:
Emergency Contact – Name :                       Tel No :	
Ⅲ. EMPLOYMENT and EDUCATION
 Present Position/ Title:                                                                
 Department or Division:                                                               
 Name of Organization:                                                                
 Address:                                                                            
 Tel No:         -        -            Fax No :         -        -             
        country code    area code          number                   country code    area code          number
 Type of Organization: □Governmental/Public  □Private  □International  □Other
 Term of Employment:  from             to present
 Describe your present duties:

                                                                              
Describe your expectation from this training course :

Note: Please TYPE or PRINT clearly in CAPITAL LETTERS and prepare three (3)            copies including the original. The words "NIL" or "N/A" should be used where applicable. Do not leave any space blank.
 Career over past 5 years	
Name of Organization	From	To	Position/ Responsibilities	
	month/year	month/year		
	     /	     /		
	     /	     /		
	     /	     /		
 Education and Training	
Name of Institution	From	To	Field of Study and Degree	
	month/year	month/year		
	     /	     /		
	     /	     /		
	     /	     /		
 Former Training in Korea or KOICA (if any):       □Yes              □No
  Program:                                    Period:        /      -      /     
                                                       month/year       month/year 	
Ⅳ. LANGUAGE PROFICIENCY
 English: 	
	Excellent	Good	Fair	Poor	Remarks	
Listening						
Speaking						
Writing 						
Reading						

 Mother Tongue :                 
 Other Languages :                                                  
 In case you speak English as a foreign language, it is required for you to certify your 
 English proficiency. Please indicate any of your English Proficiency Tests:

 □ TOEFL:               □ TOEIC:                 □ Others:              
                score                              score                              score

	

Ⅴ. MEDICAL REPORT (to be completed by an authorized physician)
 Name of Applicant:                                           	
Age:	Sex:	Height:         cm	Weight:       kg	
Blood Group:   □A     □B     □AB      □O      Other (          )	
Blood Pressure:	
1. If the applicant has a history of illness or disorders during the last 5 years, please describe the treatment and present status.

                                                                              

2. List any abnormalities indicated in the chest X-ray.

                                                                              

3. Is the applicant free of infectious diseases (AIDS, hepatitis, tuberculosis, trachoma, skin diseases, etc.)?

                                                                                

4. What opinions do you have about the overall health condition of the applicant to carry out an intensive training course away from his/her home?

                                                                              

Name of Clinic:                                                                     

Address of Clinic:                                                                   

Name of Physician:                                                            

  Date:                       Signature of Physician:                          	

Ⅵ. APPLICANT'S RESPONSIBILITIES

 If accepted as a participant, I agree:

  1) to follow the training program to the best of my ability and abide by the rules of the training institution, university, or college in which I undertake training;
  2) to refrain from engaging in political activities, or any form of employment for profit or gain;
  3) to return to my home country upon completion of my training program and to resume work in my country;
  4) not to extend the length of my training or my stay for personal conveniences;
  5) not to bring any family members (dependents) to Korea or country of training;
  6) to accept that the Korean Government is not liable for any damage or loss of my personal property; and
  7) to accept that the Korean Government will not assume any responsibility for illness, injury, or death arising from extracurricular activities, willful misconduct, or undisclosed pre-existing medical conditions; and
  8) to carry out such instructions and abide by such conditions as may be stipulated by the Korean Government in respect of my training program.

     I fully understand that my status as a participant may be terminated if I fail to make satisfactory progress, or for any other cause as determined by the Government of the Republic of Korea.

     Applicant's Name:                             Signature:                    
	
Ⅶ. OFFICIAL NOMINATION

The Government of                                           officially nominates
                                (Name of Country)
                                for participation in                              
    (Full Name of Applicant)                                         (Name of Training Course)

 as organized by the Korean Government, and certifies that:

 1) all information supplied by the applicant is complete and correct;
 2) the applicant has an adequate knowledge of and/ or expertise in the training field; and
  3) the applicant has a sufficient proficiency of spoken and written English to enable him/her to follow the training course.

 Name of Organization:                                                                
 Position/ Title:                                                                       
 Name of Authorized Official:                                                           

  Date:                             Signature: