Ministry of Foreign Affairs

Thailand International Development Cooperation Agency (TICA)

Government Complex, !ilding ("o!th #one), $ th Floor,
Chaeng%attana &oad, ang'o' ()*(), Thailand
Tel+ ,, **)- .))) ext+ /--). Fax ,, *(/- 0-*., *(/- $/.(
1mail2 tica3mfa+go+th 4e5site2 %%%+tica+thaigov+net
F16674"8I9 A996ICATI7: F7&M
I:"T&;CTI7:"
This application form is composed of five parts (part A to part E) and should be
completed in triplicate. Part A to part D should be completed by the candidate and part E
by the government authority. All parts m!st 5e filled in type%ritten form+ 1ach
<!estion m!st 5e ans%ered clearly and completely+ Detailed ans%ers are re<!ired
in order to ma'e the most appropriate arrangements+ Official authority of the
nominating Government ill then forard three copies of the certified application forms
to the Thailand !nternational Development "ooperation Agency (T!"A)# the
Government "omple$# %uilding % (&outh 'one)# (
th
)loor# "haengatta *oad# +a,si#
District %ang,o, -./-/# Thailand# through the *oyal Thai Embassy or "onsulate in the
nominating country. The nominee is re0uired to attach medical report or health status
certification. :o consideration %ill 5e given to the late s!5missions or incomplete
applications=doc!ments+
Co!rse :ame1
222222222222222222222222222222222222222222222222

A+ 91&"7:A6 8I"T7&>
Title Family name Middle name Given name "ex
(as sho%n in passport and 'indly attach the copy of yo!r passport, information
%ill 5e !sed for travel arrangement)

3r.
3rs.
3s.
3ale
)emale
"ity and country of birth 4ationality Date of birth
(DD533566)
Age 3arital
&tatus
*eligion
7or, address (Please complete this section as clear as
possible# information ill be used for travel arrangements.)
8ome address (Please complete this section as clear as
possible# information ill be used for travel
arrangements.)
999999999999999999999999999999999999999999999999
999999999999999999999999999999999999999999999999
999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999
)a$ 4o1 ("ountry "ode 5
Area "ode 5
4umber)
Telephone 4o1 Telephone 4o1
)a$ 4o1
International Airport=City for depart!re 1
;pdate email address 2
4ame and address of person to be notified in case of emergency1

Telephone 4o1 *elationship of this person to you1
(Please
attach
photograph
Page 1 of 3 pages
6ang!ages 1 &1AD 4&IT1 "91A?
3other tongue 122222222.
E$cellent Good )air E$cellent Good )air E$cellent Good )air
English
Other222222222222.
1nglish 9roficiency Test (please attach) T71F6 "core 222. I16Ts "core 222..
(only a candidate for a degree course) 7ther (specify) 22222222222222222222.
1D;CATI7: &1C7&D
Education !nstitution "ity 5 "ountry
6ears Attended
Degrees# Diplomas
and "ertificates
&pecial fields of
study
)rom To
8ave you ever been trained in Thailand: !f yes# hat course# here and for ho long:
222222222222222222222222222222222222222222222222
222222222222222222222222222222222222222222222222
)or a candidate for a degree course# please give a list of relevant publications5researches (do not attach details)
222222222222222222222222222222222222222222222222
222222222222222222222222222222222222222222222222
222222222222222222222222222222222222222222222222
222222222222222222222222222222222222222222222222
222222222222222222222222222222222222222222222
+ 1M967>M1:T &1C7&D2 !t is important to give complete information. )or each post you have
occupied# give details of your duties and responsibilities.
Present or most recent post1
Dates from 999999999999999 to 9999999999999999
Description of your or,#
including your personal responsibilities
Title of your post1
4ame of organisation1
Type of organisation1
Official address1
Previous post1
Dates from 999999999999999 to 99999999999999999
Description of your or,#
including your personal responsibilities
Title of your post1
4ame of organisation1
Type of organisation1
Official address1
Page 2 of 3 pages
C+ 1@91CTATI7:"
Please describe the practical use you ill ma,e of this training5study on your return home in relation to the
responsibilities you e$pect to assume and the conditions e$isting in your country in the field of your training.
(give the attached paper# if necessary)
D+ &1F1&1:C1" (only a candidate for a degree course please attaches the recommendation letters from to persons
ac0uainted ith your academic and professional e$periences.)
! certify that my statements in anser to the foregoing 0uestions are true# complete and correct to the best of my
,noledge and belief.
!f accepted for a training aard# ! underta,e to 1;
(a) carry out such instructions and abide by such conditions as may be stipulated by both the nominating government
and the host government in respect of this course of training<
(b) follo the course of training# and abide by the rules of the =niversity or other institutions or establishment in
hich ! underta,e to train<
(c) refrain from engaging in political activities# or any form of employment for profit or gain<
(d) submit any progress reports hich may be prescribed<
(e) return to my home country promptly upon the completion of my course of training.
! also fully understand that if ! am granted a felloship aard# it may be subse0uently ithdran if ! fail to
ma,e ade0uate progress or for other sufficient cause determined by the host Government.
&ignature of applicant1 22222222222222222222....
Printed name1 2222222222222..22222222222
Date1 22222222222222222.22222.2222
1+ G7A1&:M1:T A;T87&I"ATI7:1 To be completed by the nominating Government or the
agency from hom the nomination has been invited.
! certify that# to the best of my ,noledge#
(a) all information supplied by the nominee is complete and correct<
(b) the nominee has ade0uate ,noledge and e$perience in related fields and has ade0uate English
proficiency for the purpose of the felloship in Thailand.
On return from the felloship# the nominee ill be employed in the folloing position1
Title of post 22222.22222.222222222222222222222222..22..
Duties and responsibilities22222222222.2..222.2222222.22222222..
222.222222222222222222222222222222.222222222
2222222222222222
Signature of responsible Government official
Official stamp1 Title1 ...222222.2222222.2222.22222
Organisation1 22222222222222222222.
Official address1 2222222222222222222
2222222222222222222.
2222222222222222222.
Date1 2222222222222222
Page 3 of 3 pages
Attachment
M1DICA6 &197&T
4ame of 4ominee 22222222222222222222222222
"ountry22222.2222222222222222222222222
Age 1 222 &e$ 1 22222
Physical E$amination (To 5e filled in 5y physician)
8eight 2222. "ms. 7eight 22....2.,gs. %lood Pressure 222.2 mm.8g. Pulse 22.2..5min.
>ision *ight .2..222 +eft 222...... Eyes 222222.2... 7ith glasses 5 7ithout glasses
"hec, each item in appropriate column
Items :ormal A5normal Additional Comments
General 22222222222222222222
&,in# &calp 22222222222222222222
+ymph nodes 22222222222222222222
Eyes 22222222222222222222
Ears 22222222222222222222
7toscopic 1xam
4ose 22222222222222222222
Pharyn$ ? tonsils 22222222222222222222
Teeth 22222222222222222222
Thyroid gland 22222222222222222222
+ungs 22222222222222222222
8eart 22222222222222222222
Abdomen 22222222222222222222
+iver 22222222222222222222
&pleen 22222222222222222222
8ernia 22222222222222222222
E$ternal genitalia 22222222222222222222
*ectal e$am 22222222222222222222
>ertebrae 22222222222222222222
+ocomotor 22222222222222222222
*efle@es 22222222222222222222
3ental health status 22222222222222222222
Page 1 of 2 pages

6A7&AT7&> 1@AMI:ATI7:"
%lood group 22222..222. %lood film for malaria 2..2..2222222.. 8b 222222.2. gmA
7%" 22222222222222222 "ells5cu.mm.
Differential P34 22222. A +ymp 222.22 A 3ono 222..22 A Eos 222..2.. A
%aso 2222222..2 A %and 222222222 A %last 2222222. A
=rinalysis 1 "olour 222222.. &p. Gr 2222222 p8 22222. &ugar 222222222.
Alb 222222. %lood 222..222. Betones 22.222. %lie2222..22222..
3icro 1 7%" 222.22.58P).# *%" 2222258P).# Epethelial22222. 58P).
"asts 2222222225 8PD.# Others 22222222222222..22222222
&tool e$amination for parasite ? Ova 2222222222222222222222222222222..
"hest C D *ay report 2222222222222222.2222222222222222222222
=rine pregnancy test 22222222222222222222222222222222222222..
!s the nominee able physically and mentally to carry on intensive study aay from home:
222222222222222222222222222222222222222222222222
!s the nominee free from infectious diseases (such as tuberculosis# leprosy# syphilis and filariasis) and other conditions
(such as psychosis and drug addiction) hich could present ris,s for anyone during the felloship period:
222222222222222222222222222222222222222222222222
Does the nominee have any condition or defect hich might re0uire treatment during the felloship period:
222222222222222222222222222222222222222222222222
! certify that the applicant is medically fit to underta,e a course in Thailand.
)ull name and address of Physician signature 22222222222..3.D.
E$amining physician (printed) (222222222222222222)
2222222222222 Date22222222222222222222
2222222222222
2222222222222
Telephone1 222222222..
(printed)
e;mail1 22222222222..
Page 2 of 2 pages