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Learning Route Making Rangelands Secure

APPLICATION FORM LEARNING ROUTE

MAKING RANGELANDS SECURE


January-February 2012
TO BE FILLED OUT BY THE PERSON NOMINATED FOR A PLACE ON LEARNING ROUTE (KENYA-TANZANIA, January-February 2012 EXACT DATE TO BE CONFIRMED) LAST NAME SEX
Female Male

NAME DATE OF BIRTH


(Day/Month/Year)

OTHER NAMES CITIZENSHI P AGE

NATIONALITY COUNTRY OF RESIDENCE/WORK CITY PHYSICAL ADDRESS E-MAIL ADDRESS TELEPHONE NUMBER FAX CELLPHONE DETAILS OF NEXT OF KIN IN CASE OF EMERGENCY NAME OF ORGANISATION HAS YOUR ORGANISATION COMPLETED APPLICATION FORM FOR THE LEARNING INTIATIVE POSITION IN ORGANISATION WHAT ARE YOUR MAIN ROLES AND RESPONSIBILITIES IN ORGANISATION, DEPARTMENT OR PROJECT?

YES

NO

WHAT KNOWLEDGE,
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Learning Route Making Rangelands Secure CHARACTERISTICS, SKILLS AND CAPACITIES DO YOU HAVE THAT WILL ENABLE YOU TO CONTRIBUTE TO AND MAKE THE MOST OF THE LEARNING EXPERIENCE TO BE PROVIDED ON THE LEARNING ROUTE?

HOW CAN YOU CONTRIBUTE TO POSITIVE CHANGE WITH THE KNOWLEDGE YOU GAIN ON THE LEARNING ROUTE?

IDENTITY DOCUMENT PASSPORT NUMBER NATIONAL ID NUMBER SPOKEN LANGUAGES Issuing date Issuing date Expiry date Expiry date

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Learning Route Making Rangelands Secure

LEARNING ROUTE FEE AND SCHOLARSHIP


The Learning Route has a cost of USD$ 4057 plus flights - People and organisations not able to completely cover the fee may apply for a partial or full scholarship PLEASE FILL OUT THIS TABLE ACCORDINGLY. The organisation will cover the USD$ 4057 fee for the participation of nominated person on the learning route, plus the cost of the flights to Nairobi and from Kilimanjaro (Arusha). The organisation is unable to cover the fee, but can cover the costs of the flights. We explain the situation and request a part-scholarship in the attached letter. The organisation is unable to cover the fee for the learning route and the flights. We explain the situation and request a full-scholarship in the attached letter. Mark X

THANK YOU VERY MUCH FOR COMPLETING THE APPLICATION AND FOR YOUR COMMITMENT TO PARTICIPATE IN THE LEARNING INITIATIVE Please send the form to the following email address: ILC_Learning_Initiative@yahoo.com Before 11th November 2011 We will contact you very soon!

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