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KHESAR GYALPO UNIVERSITY OF MEDICAL SCIENCES OF BHUTAN IN COLLABORATION with Center For Tropical Medicine (CTM), Faculty of
Medicine, Public Health And Nursing, University Of Gadjah Mada as one of WHO-TDR Regional Training Center SUPPORTED BY WHO-TDR
Course Application Form6th Batch of Regional Course on
Good Clinical Laboratory Practice - GCLP (November 5 – 7, 2019) Application Deadline: Sponsorship: October 10, 2019
1. APPLICANT INFORMATION (2 persons per institution) COUNTRY :
Apply for (please tick) : Scholarship Non-scholarship
(Please fill in the name exactly as it is in applicant passport)
Personal Information – Applicant 1Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address Postal Code/ City Country Fax
Telephone number including country codeHome Address Postal Code/ City CountryEmail address
Passport number
Date of birth
Place of birth (city, country)
Present job title
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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 2
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address Postal Code/ City Country Fax
Telephone number including country codeHome Address Postal Code/ City CountryEmail address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English
Computer literacy
2. SPONSORSHIP
WHO-TDR through the course organizer offers full scholarship for 7 participants of SEAR countries which covers course materials, faculty fees, lodging, lunch and
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coffee breaks during the course, as well as travel expenses (economic fair shortest route) from country of home institution. 3. REGISTRATION This 6th Batch of Regional GCLP Course is designed as a 3 day intensive program with a maximum of 25 participants.
Registration open : October 2 – October 28, 2019Course fee per person and deadline
1. International participantsa. Sponsorship : latest by October 10, 5 PM, BST: FREE (please see 2.
sponsorship)b. Non-Sponsorship (international participant): latest by October 13, 5 PM
BST: (US$ 400)*2. National Participants: latest by October 28, 2019, free course fee only
(* includes accommodation with breakfast for 3 days)
Attach the following to this application form: The participants’ typewritten detailed Curriculum Vitae Motivation letter A scanned or copy of participants’ passport Recommendation letter from head of institution./Nomination letter Send the application package by the deadline (Sponsorship: October 10, 2019, Non-Sponsorship: October 13, 2019) by e-mail to
Contact Person: Dr Sonam Chhoden R (Email: [email protected])
Failure to provide all of the information requested may result in the rejection of your application.
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