B. P. KOIRALA INSTITUTE OF HEALTH SCIENCES, DHARAN, NEPAL

SUPPORTED BYWHO Regional Training Center (RTC) for Health Research by TDR for the South East Asia

Region, Yogyakarta, Indonesia

Course Application Form

3rd Batch of Regional Course on Good Clinical Practice - GCP (July 31 – August 2, 2017) Application Deadline: Sponsorship: June 20, 2016, Normal: July 10, 2017

1. APPLICANT INFORMATION (2-3 persons per institution)

COUNTRY :Apply for (please tick) : Sponsorship

Early Bird Registration Normal Registration

(Please fill in the name exactly as it is in applicant’s passport)

Personal Information – Applicant 1Title: Prof/Dr/Ms/Mr.Family Name

First Name (s) (as in passport)Organization

Office AddressPostal Code/ CityCountryFax

Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address

Passport numberDate of birthPlace of birth (city, country)

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Present job title

Job description

Knowledge of English Written: Average___ Good___ Excellent ___Spoken:Average___ Good___ Excellent ___

Computer literacy Word: Proficient___ Need Help___ Never Used____

Excel: Proficient___ Need Help___ Never Used____

PowerPoint: Proficient___ Need Help___ Never Used____Internet: Proficient___ Need Help___ Never Used____

Personal Information – Applicant 2Title: Prof/Dr/Ms/Mr.Family Name

First Name (s) (as in passport)Organization

Office AddressPostal Code/ CityCountryFax

Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address

Passport numberDate of birthPlace of birth (city, country)Present job title

Job description

Knowledge of English Written: Average___ Good___ Excellent ___Spoken: Average___ Good___ Excellent ___

Computer literacy Word: Proficient___ Need Help___ Never Used____

Excel: Proficient___ Need Help___ Never Used____

PowerPoint: Proficient___ Need Help___ Never Used____Internet: Proficient___ Need Help___ Never Used____

Personal Information – Applicant 3Title: Prof/Dr/Ms/Mr.Family Name

First Name (s) (as in passport)

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Organization

Office AddressPostal Code/ CityCountryFax

Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address

Passport numberDate of birthPlace of birth (city, country)Present job title

Job description

Knowledge of English Written: Average___ Good___ Excellent ___Spoken: Average___ Good___ Excellent ___

Computer literacy Word: Proficient___ Need Help___ Never Used____

Excel: Proficient___ Need Help___ Never Used____

PowerPoint: Proficient___ Need Help___ Never Used____Internet: Proficient___ Need Help___ Never Used____

2. SPONSORSHIP

WHO-TDR through the course organizer (BPKIHS) offers full scholarship for 7 participants of SEAR countries which covers course materials, faculty fees, lodging (not applicable for faculty members of BPKIHS), lunch and coffee breaks during the course, as well as travel expenses (economic airfare) from country of home institution.

3. REGISTRATION

This 3nd Batch of Regional GCP Course is designed as a 3 days’ intensive program with a maximum of 25 participants. Registration open : May 20 – July 10, 2017

Course fee per person : a. Sponsorship : May 20 –June 20, 2017: FREE (please see 3. sponsorship)b. Early Bird : May 20–June 30, 2017: NPR 34,000 (US$ 320) *c. Normal : July 1–10, 2017: NPR 42,000 (US$ 400) *

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*ticket, accommodation and lump sum are not included

Attach the following to this application form (can be downloaded in http://bpkihs.edu/gcp2017): The participants’ typewritten detailed Curriculum Vitae Motivation letter A scanned or copy of participants’ passport (international participants) Recommendation letter from head of institution.Send the application package by the deadline (Sponsorship: June 20, 2017, Normal: July 10, 2017) by e-mail to:

Health Research and Capacity Building Committee, Office of the Dean, Academic Administration, B. P. Koirala Institute of Health Sciences, Dharan NepalContact Person: Mr. Gaurab Sanjyal (Email: gcp @bpkihs.edu ) Failure to provide all of the information requested may result in the rejection of your application.

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