ࡱ> Y bjbjzKzK Hv! b! b zF#F#F#F#F#Z#Z#Z#8#$Z#I"%&&&&(((HHHHHHH$LjO|HF#(((((HF#F#&&HH***(jF#&F#&H*(H**RcDF&3&Gz(WE}HH0IuEbO)O<FFfOF#=G@((*(((((HH*(((I((((O(((((((((N ": Annex II WESTPAC TRAINING COURSE ON DEVELOPMENT OF COUPLED REGIONAL OCEAN MODELS UNESCO/IOC Regional Training and Research Center on Ocean Dynamics and Climate Qingdao, China, 12-23 June 2017 APPLICATION FORM The Government of ....... proposes the nomination of the following expert to participate in the Training Course. Family name FORMCHECKBOX  Dr /  FORMCHECKBOX  Mr /  FORMCHECKBOX  MsFirst nameGender FORMCHECKBOX  Male  FORMCHECKBOX  FemaleNationalityDate of birthEducation level FORMCHECKBOX  Bachelor  FORMCHECKBOX  Master  FORMCHECKBOX  PhD Graduated from: Major: Supervisor/Advisor: Job titleAffiliationYears of experience in current jobAddressTel. number(s)Fax number(s)Email(s)Contact person, in case of emergencyDietary Restriction FORMCHECKBOX  None  FORMCHECKBOX  No pork  FORMCHECKBOX  No beef  FORMCHECKBOX  Bachelor  FORMCHECKBOX  Other, please specify Major and/or Research AreaPrevious Training Courses/Workshops FORMCHECKBOX  No  FORMCHECKBOX  Yes, please specify the workshop titles: (a) (b) Brief statement of research activities that is linked to this training course, and related publication if any (This part is crucial for qualifying, so separate pages could be annexed to this form) Please provide with name and E-mail address of two referees whom can be contacted to support your applicationReferee #1NameJob titleAffiliationEmailTelReferee #2NameJob titleAffiliationEmailTel Financial assistance  FORMCHECKBOX  I could cover my expense.  FORMCHECKBOX  I would apply for the financial assistance.  FORMCHECKBOX  Fully (including round trip airfare, accommodation);  FORMCHECKBOX  On airfare in the amount of US$_____  FORMCHECKBOX  On accommodation.  Date: . ... 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