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Application Form Please complete all parts of this application form in BLOCK CAPITALS

Brunei – U.S. English Enrichment for ASEAN

PLEASE INDICATE THE COURSE THAT YOU WISH TO ATTEND BY TICKING (

English for Teacher-Trainers

) THE BOX

/

English for Officers and Diplomats 1. PERSONAL DETAILS Name (as it appears in your passport) _________ Natthakrit Title (Mr/Ms/Mrs/Dr):

Contact address: Email address: Telephone number: Age:

Sex:

Male

Female

/

37 M.3 T. Bankao Panthong Chonburi, Thailand. 20160 kru.english@hotmail.com Mobile number:

Date of birth (dd/mm/yy):

34

Nationality:

Phuthawi

087-584-8970

10/03/1978

Thai

2. PASSPORT DETAILS* Passport Number (if you don’t have one yet, please apply for it ASAP and submit to us a copy) Place of issue: Issue date: (dd / mm / yy)

F 607474

Ministry of Foreign Affairs 07/06/2012

Expiration date: (dd / mm / yy)

Does your nationality require you Yes to obtain a visa to enter Brunei? Does your nationality require you to obtain a visa to enter the Yes U.S.A.?

06/06/2017

No No

*Important Reminder Your passport must be valid for at least six months after the completion of the course.

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form 3. SPECIAL REQUIREMENTS** Dietary requirements (please specify): Do you have any medical conditions that the University should know about? Information provided will not affect your admission into the programme. If none, tick box. / 4. EMERGENCY CONTACT DETAILS Please give details of someone we can contact in an emergency while you are in Brunei: Name:

Relationship:

Jira Chalermsak

Telephone number:

038-447-241

Contact address:

37 M.3 T. Bankao Panthong Chonburi, Thailand 20160

Director

Email address:

Please answer the following section if you intend to apply to our English language courses. 5. ENGLISH LANGUAGE PROFICIENCY Please indicate your level of English (students are assessed to ensure they are at a suitable level): Intermediate

/

Upper Intermediate

Advanced

Upper Advanced

Have you taken an IELTS exam or any other English-proďŹ ciency tests? Yes No / If so, please indicate the date, the test / exam, and the result: Date: Test / Exam: Overall Band Score: (please submit a copy of your score report with this application form.)

**We do not discriminate against people with disabilities or medical needs and make all reasonable efforts to accommodate their needs.

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form 6. ACADEMIC DETAILS Please state your highest academic qualiďŹ cations. Name of institution / university:

Science Based Technology Vocational College (Chonburi)

Name of current degree: (e.g. BA etc.)

Bachelor

Field of study: (e.g. Linguistics)

English

7. EMPLOYMENT DETAILS Organisation/ Department

Designation

Nature of Job

Period (dd/mm/yyyy) From

General Department

Teacher

Teaching

2007

To

present

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form 8. MEDICAL REPORT (to be completed by an authorised physician) Name of applicant: Age:

Natthakrit Phuthawi

Sex:

34

Blood Group: A

/

B

Height:

Male

AB

O

Is the person at present in good health? Yes.

Is the person free of infectious diseases (AIDS, tubercolosis, etc.) Yes.

160

Weight:

67

Other Is the person examined physically and mentally able to carry out intensive training away from home? Yes.

Does the person examined have any condition or defectroma, skin disease etc. (including teeth) which might require treatment during the course?

List any abnormalities indicated in the chest x-ray. Pregnancy test (for women)

I certify that the applicant is medically ďŹ t to undertake a course in Brunei Darussalam and the U.S. Name of physician: Address of clinic: Telephone: Email Date: Signature of Physician:

Seal of Clinic:

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form 9. QUESTION Please explain in 100 words how you plan to use the knowledge and skills gained from this course to beneďŹ t your country and ASEAN. Language is very important for Thai. And the ASEAN will be in 2015.There are a total population of 577 million people in ASEAN 10 countries for which the economic is the main interest and to encourage children and youth to learn English, Chinese, etc. Development of children and young people using Media and Modern technology. Building roads to transport goods. This includes schools - the sector responsible for preparing human resources as me. If I get this opportunity, I really sure that I can teach my student with my knowledge. I think my best experience from seaboard can help me to create activities for teaching English. And important I love to improve and develop my English and I love teaching English. My happiness is my students can communicate in English.

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form

10. HAVE YOU EVER BEEN CONVICTED BY A COURT OF LAW OF ANY COUNTRY? Yes

No

/

If “yes”, please provide details:

11. PHOTOGRAPH AND VIDEO AGREEMENT RELEASE FORM I am aware that photographs and videos may be taken on the Brunei – U.S. Project with Universiti Brunei Darussalam (UBD). In addition, I am aware that UBD may use photographs or video of me for various marketing / promotional purposes. Photographs and videos of me may be seen on the Brunei – U.S. Project website. I understand that these photographs or videos will be used for educational purposes only. I do allow photographs and video

/

I do not allow photographs and / or video

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form 12. NOMINEE DECLARATION AND SIGNATURE I ________________________________________ of __________________________________________ (Name) (Country) (a) certify that the information contained in this application form, and in all the support documents being provided as a part of this application, is accurate and complete to the best of my knowledge. (b) will be personally liable for all medical expenses incurred during my stay in Brunei and the United States of America, other than those covered under Personal Insurance or any equivalent insurance policies offered by The Brunei-U.S. English Language Enrichment Project for ASEAN 11-Week English Language Programme. Participants are personally liable for all medical expenses beyond what is covered by the insurance policy. As the coverage is limited, participants are advised to make their own arrangements to obtain adequate medical insurance coverage for their stay in both Brunei Darussalam and the U.S. If accepted for the training programme, I undertake to:(a) carry out instructions and abide by such terms and conditions as may be stipulated by the nominating and host governments in respect of this training programme; (b) abide by the rules and regulations of the training institution in which I undertake to study in or be trained under; (c) refrain from engaging in any political activities and/or any form of employment for proďŹ t or gain; (d) return to my home country upon completion of the training; and (e) discontinue the course should I be found guilty of misconduct or be medically unďŹ t (as advised by an accredited physician) to meet the requirements of the programme. I fully understand that if I fail to comply with the terms and conditions of the training programme, and/or any of the above declarations are found to be untrue, the award will be terminated with immediate effect and I would be liable to depart from the host country of the programme on my own expenses.

Signature of Nominee:

Date:

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


Application Form 13. OFFICIAL DECLARATION (to be completed by the nominating government) On behalf of the government of ___________________________________________, (Country) I ___________________________________________________________, certify that: (Name of Official) (a) I have examined the entire document and accompanying certificates quoted by the nominee of this application and I am satisfied that they are authentic and related to the nominee; (b) the nominee is medically fit and free from infectious disease and there is no reason to suppose that the nominee is other than fit to undertake the journey to Brunei Darussalam and/or the United States of America for the duration of the training; and (c) the nominee has attained a level of proficiency in both spoken and written English to enable him/ her to follow the course of study/training for which he/she is nominated. I nominate (Mr/Mrs/Miss/Dr/Prof) ________________________________________ holding Passport No. _________________________ _____________________________________ (Name of Official)

________________________________________ (Signature)

_____________________________________ (Name of Organisation)

________________________________________ (Designation)

___________________________________________________________________________________ (Address of Organisation) _____________________________________ (Email address)

________________________________________ (country code) + (Area code) + (Office tel. no.)

_____________________________________ (Date)

________________________________________ (country code) + (Area code) + (Office fax. no.)

Application Forms must reach the Ministry of Foreign Affairs & Trade, Brunei Darussalam, by 1st July 2012.


application form