Application For "Need For Training" Certificate Form - Republic Of The Philippines Page 2
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2TRAINING/SCHOLARSHIP GRANT
INCLUSIVE YEAR
________________________________________
____________________
________________________________________
____________________
________________________________________
____________________
PROFESSIONAL LICENSES/BOARD CERTIFICATES/ELIGIBILITIES
YEAR OBTAINED
DATE OF
________________________________________
12/31/2001
________________________________________
12/31/2001
________________________________________
12/31/2001
EMPLOYMENT DATA:
PRESENT POSITION/OCCUPATION _______________________________ PERIOD OF EMPLOYMENT: FROM 12/31/2001 TO 12/31/2001
NAME AND COMPANY OF PRESENT EMPLOYER __________________________________________ TEL. NO.
ADDRESS OF PRESENT EMPLOYER _____________________ FAX NO.
BRIEF DESCRIPTION OF WORK _______________________________________
DO YOU HAVE ANY PENDING ADMINISTRATIVE/CRIMINAL CASE?
YES
NO
IF YES, GIVE PARTICULARS
____________________
_________________________________________
REQUEST FOR THE “NEED FOR TRAINING CERTIFICATE”:
INTENDED SPECIALIZATION OF TRAINING ________________________ PERIOD OF TRAINING: FROM 12/31/2001 TO 12/31/2001
PLACE OF TRAINING ________________________________________
ARE YOU A PREVIOUS EVP PARTICIPANTS?
YES
NO
INCLUSIVE DATES:
HOW WILL YOUR EVP FINANCED: (indicate sponsoring agency and attch supporting documents including course outline/brochure)
GOVERNMENT FINANCED ___________________________________
PERSONALLY FINANCED _____________________________________
NON-GOVERNMENTORGANIZED FINANCED _______________________________________
REASON FOR TRAINING _____________________________________
Job Preferences and rank each item:
Government
Administrative
Service
Educational
Private Practice
Others
Research
Manufacturing
I hereby declare under penalties of perjury that the answers given above are true and correct to the best of my knowledge and belief.
I, _________________________________ hereby agree to comply with
the two-year home residency requirement
of the Exchange
Visitor’s Program (EVP) and shall not seek under any circumstances a waiver of this requirement. As part of the EVP, I also commit to practice in
the specialty as to which I was trained for.
Date:
Signature of Participant: ____________________
NOTE:
1.
Application Form should be accomplished in six (6) copies.
2.
Documents coming from the United States should be authenticated by the Philippine Embassy/Consulate.
ENCLOSURE:
1.
Certification of appointment for Acceptance from the university or training Institution in the U.S.
2.
Valid Certificate of registration and Professional License from PRC.
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