Application No. 5.

Nationality

CENTRE FOR SPACE SCIENCE AND TECHNOLOGY EDUCATION IN ASIA AND THE PACIFIC
(AFFILIATED TO THE UNITED NATIONS)
APPLICATION FORM FOR
SIXTEENTH POST GRADUATE COURSE IN REMOTE SENSING AND GIS
(JULY 1, 2011 TO MARCH 31, 2012)
AT
INDIAN INSTITUTE OF REMOTE SENSING (NRSC), DEHRA DUN. INDIA

RSGIS-16
(For office use only)

Date received

1. Name : Mr./Ms./Dr. Justine Jose Polotan de la Cruz

First Middle Last
September 10. 1987 Manila
2. Date of Birth _ 3. Place of Birth
Male Filipino
4. Sex (Male/Female) _

6. Contact Information: Complete Mailing Address (Valid until what date):

Velazquez St. Diliman, Quezon City 1101

Republic of the Philippines

Telephone: (Give complete Phone No. with all codes) Home :+6329266637 Offjce:+6323785422

pax.
Fax:_ +6329247678
+6329247678 E-mail " Justinejosedelacruz@gmail. com

7. Permanent ContactAddress (Ifdifferent from above)

19 Mahiyain st. Teacher's Village West Diliman, Quezon City,
1101 Republic of the Philippines

Telephone: (Givecomplete Phone No. with all codes) Home ;+6329266637Qffjce @ +6323785422
Fax" +6329247678 E-mail ' justinejosedelacruz@gmail.com

Important:
a) Interested persons may detach last 4 pages fromthis brochure and usethem asApplication Form.
b) It is essential that full passport details are mentioned in theApplication Form.
c) Application Formswithout passport details may not be considered.
 Date ofjoining this Organization September, 2010

8. ACADEMIC QUALIFICATION*
Degree/ Durationof University/ Yearof Grade Major
Diploma Course Institution Passing Class Subjects
B.S. Geography 4 yearsUniversity of the Philippi > 2009 Urban and Rural, Transport,Movement,
Diliman Medical, R.S., Air Photo Interpretation

@(Enclose copies ofDegree/Diploma/Cer

tificates/marks/grades obtained, etc.)

Major Subject in last examination Area of Specialization

Medium of Instruction/Language En91:i-sh TOEFLScore (Proficiency in English).

Note: Enclose certified copies ofmarks/grade and degreeTOFEL certificates and their certified translations in English

9. DETAILS OF EXPERIENCE OF LAST FIVE YEARS

(a) Present Position Research AssistantPresent Responsibilities R'S ' Image Analysis

Data Analysis, Report Writing and Presentation, Administrative

Organization Marine Science Institute, Velazquez st. UP campus Diliman, Quezon City
(CompleteAddress)

*Attach additional sheets giving details ofyour technical activity during last one year2008-09

(b) Experience during past 15 years:

NameofOrganization Post(s)held Natureofworkdone Duration

Conservation International Research AssistantData Analysis, Report Writing and Presentation1 month
Philippines
14.
17. How do you foresee
proposethe
to meet
PG Diploma
the international
Course intravel
RS &and
GISstay
will expenses
help you? in India?

10. (a) Activity and projects in which your organization is engaged*

Remote Sensing, GIS application, Coastal resource management, environmental

monitoring, marine biological and oceanographic research, environmental modelling,
marine resource protection and conservation

(b) Main technical/scientificfacilities available in yourorganization*

(including approximate number and type ofcomputers, type of software available, etc.)

1 i7, lx Quad (Xenon) , 2x Core 2 Duo, 5x Pentium 4,

ArcGIS 9.3.1, Envi 3.6, Matlab r2010 (a,b) , M.S. Office 2007,
Google Earth Professional, Cmap, Delft, Ocean Color and Oceanographic Instruments

11. Have you done anyothercoursefrom CSSTEAP (ifyes, then please give details including theme and year)

No.

12. PASSPORT PARTICULARS

PassportNumber PlaceofIssue Dateofissue Passportvalidupto IssuingAuthority

XX4523106 Manila 09 Sep 2009 08 Sep 2014 Department of

Foreign Affairs
Manila

* Passport details are necessaryto consideradmission.

13. Physical Fitness

(a) Are you suffering from any recurring/chronic/serious disease which may affect your study
program in India? No.
(b) If yes, please specify nature of illness (you must also attach medical fitness certificate from a
qualified doctor)

Through application for CSSTEAP financial Assistance or TCS fellowship

15. Have you applied for TCS fellowship ? If so, enclose a copy of the duly filled application form, submitted
to Embassy / High Commission of India in your country. (Applicable for only those candidates who are from the
countriesforwhich TCS Fellowship is available, as specified under"Financial assistanceto participants" in the brochure.)
Application in Process

16. Which elective in the Second Module ofthe Course you wish to choose (Tick Mark)
(Agriculture & Soil, Water Resources, Marine Science or Advances in R.S. & GIS Technology).

The PG diploma Course would give me the necessary expertise to perform

more in-depth academic research, it will also boost my professional
career in Remote Sensing.
 DECLARATION BYTHE CANDIDATE
I have read the announcement brochure and will abide by the rules and regulations of the Centre. I
have made / am making / not madetravel arrangements for attending the course and local expenses
forthe period of stay in India. , ,
Date: J<W ^ ^ H J^W*$JolokwitkU*i
r\ \ Di;r '@@ , Signature of Candidate
Place: Q-Ut2em <-vSf @ *** l|fPxVU&

16. SPONSORING/NOMINATING AGENCY CERTIFICATE

Mr./Ms./Dr. Justine Jose Polotan de la Cruz is sponsored byMarine science

institute, univ. of the Philippines to attend tne Sixteenth P q Course in p?s & GIS. We envisage
to utilise his / her experience in specific tasks of our organization/agency. The candidate will be allowed
to carry out the project work for a period of one year in his/her country and will be provided with all the
facilities required forthe same.
/(a) He/She will not be provided international travel support.
ylb) He / She will be / will not be provided financial assistance for the period of stay in India.
j/(c) He / She possesses adequate knowledge of English Language required for the course.

Place: ,A
Name: Maria Gourdes McGione, Ph.D. Signature ^
Designation:Director, Marine Science Institute vY/
Phone:+6329223962 Va " ^
Fax: +6329223962 Seal ofthe Nominator/Sponsorer
E-mail:mcglonemOupmsi .ph

17. FORWARDING NOTE BYTHE RESPECTIVE COUNTRY'S EMBASSYIN INDIA

This is to forward the application of Mr./Ms./Dr. "H @ C @ kOiAcA c\ i> . A-|(gre^ of

^wibeis^ o-f -nu ^HV ^ ^ fMff^ (Specifvthe Country Name here)for9 months Post

Graduate Course in RS & G!S of CSSTEAP.

Date: Signature

Name:
Designation: Seal of the Embassy /High Commission

N.S.: Please sent an advance copy of the form, duly signed by the sponsoring organization, to the Course Director,
CSSTEAP, MRS Campus, 4, Kalidas Road, Dehradun - 248 001 (India) by FAXfor quick processing. Original copyto
be sentthrough Embassy/High Commission ofrespective countries at New Delhi duly signed bythesponsorer.

IMPORTANT
Theapplicationwhich is notcomplete in all respects Islikelyto berejected
Applicantshould attach copiesofcertificatesof
(a)Medical fitness
(in case ifany medical information requiring attention is hidden and iffound during thecourse,the centrewill be compelled to send the
candidateback home)
(b)Highest degreeobtained (Degreecertificateand marksheet)
(c)Proficiency In English.
Degree Certificates, ifnot In English, may please betranslated in English and attested by the Head oftheorganization.
me(^callY|f
iyoaf
it for employment/permanency

CS Form 211
Medical Certificate PHILIPPINE CIVIL SERVICE
For Employment

INSTRUCTIONS

1 This medical certificate should be accomplished by a government physician.

2. Attach this medical cer
tificate to original appointments, reinstatement and
permanency

FOR THE PROPOSED APPOINTEE

NAME. (Last, First, Middle or if married, maiden name) AGENCY

Of ^|
ADDRESS: PROPOSED
l\ MaW^n &. TiiW} ^Hfljt \ >t&+ M** , *t
oi*t
y DESIGNATION

\ |lH
AGE i*> CIVIL STATUS ^je SEX j\

FOR THE PHYSICIAN

I hereby certify that I generally examined the above-
NameeNndwidual and found her/him to be physically and obiSSUees
OF PHYSICIAN CERTIFICATE NO. OTHERTNFORKMTIUN
ABOUT THE APPOINTEE
H-~ #rv?
Official Designation Height (barefoot) Weight (stripped)
67. H 104 ft*-
AGENCY DATE EXAMINED X-RAY RESULTS\
10 - W^- lo

.B. A medical certificate issued for purposes of employment in the University of the
Philippines (Original, reappointment or permanent) MUST include X-RAY or
FLUOROSCOPIC RESULTS.
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