e-Learning Monitoring & Evaluation Course Application Form

Amref Health Africa

AMREF HEALTH AFRICA DIRECTORATE OF CAPACITY BUILDING
e-Learning Monitoring & Evaluation course


INSTRUCTIONS:

This application/nomination form should be completed by an applicant who intends to undertake a training course by Amref Health Africa. All question items pertaining to the applicant MUST be filled.

Section A: Background information
Applicant’s Name (as in passport or Identification Card):(*)
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Sex (M/F)
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Date of Birth: (DD/MM/YYYY)(*)
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Nationality:(*)
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Passport/ID No:(*)
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Date of Issue:: (DD/MM/YYYY)
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Place of Issue:
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Expiry Date of Passport: (DD/MM/YYYY)
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Name of Employer/Institution:
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Your Email(*)
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Your Contact Address (Post and Phone/Mobile)(*)
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Emergency Data: Person to be notified (Name and Contact details):(*)
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Educational background or corresponding institutions attended:
Name of Institution/ College/ University attended (1)
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Dates:
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Qualification Achieved:
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Name of Institution/ College/ University attended (2)
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Dates:
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Qualification Achieved:
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Name of Institution/ College/ University attended (3)
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Dates:
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Qualification Achieved:
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A brief summary of the working experiences:
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Title of present position:
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Date assumed present post: (DD/MM/YYYY)
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Description of present duties and responsibilities:
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Briefly indicate reasons for applying for this course. What do you expect from it and how might it help you in the present job or future plans?
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State if you have any request about which you wish the training organizers to make special consideration during the training?
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Where did you get information about this course?
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Sponsorship Details
Sponsorship
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If “Other” please give details of sponsoring agent below:
Name of Sponsoring Agent:
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Contact Postal Address:
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Website
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Title of Contact Person
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Name of Contact Person
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Contact Telephone:
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Contact Email:
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Work station (County)(*)
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Amref Health Africa will use the information you have provided on this form to respond to your enquiry/comment or to direct your enquiry/comment to an appropriate Amref local office. We may also use the information to maintain future contact with you in order to send news of the latest Amref activities. Amref complies with the data protection laws in Kenya and takes all reasonable care to prevent any unauthorised access to your personal data. You agree to these terms and conditions by clicking the submit key below.

Are you a robot?
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