APPLICATION FORM ITP 2015:

Training Course Road Safety in Low and Middle Income

Countries: Challenges and Strategies for Improvement
1. Personal information
SURNAME (family name) (AS ON PASSPORT): CASTAEDA HERRERA
FIRST NAME(S) (AS ON PASSPORT):

BRAYAN ANDREY

GENDER:

Male /

Female

NATIONALITY:

COLOMBIAN

BIRTH DATE:

20/01/1993 (dd/mm/yyyy)

PLACE OF BIRTH (TOWN):

MESETAS ( META )

PLACE OF BIRTH (COUNTRY):

COLOMBIA

MARITAL STATUS:
SINGLE /

MARRIED /

SEPARATED /

NUMBER OF CHILDREN:

DIVORCED /

WIDOW(ER) /

OTHER

ICE:
( +57) 313 838 43 49
(CONTACT DETAILS OF PERSON TO BE
NOTIFIED IN CASE OF EMERGENCY)
(name + telephone number,
incl. Country code/area code + email address)
PASSPORT NUMBER (if available):

NATIVE LANGUAGE:

SPANISH

2. Contact information
HOME ADDRESS:

STREET 26 B #20A 10 VILLAVICENCIO META COLOMBIA

(Street + number + place + region + country):

EMAIL ADDRESS:

BRAYAN.CASTANEDA@AIESEC.NET

PHONE NUMBER:

(+57) 304 360 57 05

(incl. Country code/area code)

Application form ITP 2015 - p. 1 of 5

3. Academic information
HIGHEST DIPLOMA (LEVEL):

TECHNICIAN

DIPLOMA TITLE:

OCCUPATIONAL TECHNICIAN IN LANGUAGES

ACADEMIC INSTITUTION (DIPLOMA):

TECHNICAL

ACADEMIC BACKGROUND:
List chronologically starting with the least recent, the details of all higher education, as well as
professional training attended and memberships.
From
To
Name and address of the institution
3.1. obtained higher education degrees *

Field of study

Degree/year*

(university education and/or non-university programme(s))

INSTITUTE/

OCCUPATIONAL TECHNICIAN IN

LANGUAGES

2013

LANGUAGES

3.2. professional training(s)

/

3.3. memberships
/
/
/

*degree/year:
For higher education:
Degree: fill in whether you obtained a bachelor or master degree
Year: fill in the year of graduation
For professional training and/or memberships
Degree: fill in whether this was a training course or is a current membership
Year: fill in the year of the training course or start of the current membership

* To complete your application, you will need to send copies of all obtained higher education
diplomas (see items you listed under 3.1.) and corresponding transcripts (list of courses and
grades) (in English or with an English translation) together with your application form. If you
had professional training, it is advisable to also send documents related to the items you listed
under 3.2.
Without these diplomas and transcripts, the application is incomplete and cannot be
considered for admission.

Application form ITP 2015 - p. 2 of 5

4. Professional information
CURRENT PROFESSIONAL INSTITUTION:
CURRENT PROFESSIONAL SECTOR:

RESEARCH INSTITUTE
UNIVERSITY / HIGHER EDUCATION INSTITUTE
NATIONAL OR LOCAL GOVERNMENT
NGO
OTHER: specify:

DURATION OF RELEVANT PROFESSIONAL EXPERIENCE:

4.1. Current position*

From to
Job title

Description of your current work, including your personal responsibilities (max. 5 lines)

* Please send a written (future) employers statement of (re)integration in an employment

where the acquired knowledge and skills will be immediately applicable. This statement should
be in English and should also confirm the added value of the training for the applicant and the
organization.
Summarized, in this statement your employer should confirm the below:
1. Employer confirms that you are employed in his/her organization (not a copy of your
employment contract)
2. Employer confirms that you are given permission to attend the training programme from
September through December 2015, after which you resume work in your organization.
3. If applicable, employer confirms that he/she will continue your salary payment for the
duration of the training programme
4. Employer mentions the relevance of the training programme for your organization.
5. The statement should be dated and signed by your employer
Without this statement, the application is incomplete and cannot be considered for admission.

4.2. Previous position

From to
Employer (organization)
Job title

Description of your previous work, including your personal responsibilities (max. 5 lines)

Application form ITP 2015 - p. 3 of 5

5. Scholarship information
I WISH TO APPLY FOR A SCHOLARSHIP:

yes /

no

I HAVE BEEN GRANTED SCHOLARSHIPS IN THE PAST:

yes /
no
If the answer was yes, please list year + programme title + organisation who financed the scholarship:

6. English proficiency*
Indicate what is applicable to you and provide proof of English proficiency
I have taken at least 1 year of comprehensive English-based instruction at a university or
recognized equivalent.
Enclose proof of this in your application!
I have taken a TOEFL test and passed (min. total score of 550 for paper based test or 79 on an
internet based test).
Enclose proof (recent TOEFL test results)
I have taken an IELTS test and passed (min. overall band score of 6.5).
Enclose proof (recent IELTS test results)
I have taken another English test, of similar level as TOEFL or IELTS.
Enclose proof (recent test results)

* Please send proof of English proficiency together with your application form.
Without this proof of English proficiency, the application is incomplete and cannot be
considered for admission.

7. Motivation
Please state briefly (max. A4 page) the reason for applying to this programme, your main
field of interest within the programme and how you hope to benefit from the programme. If
you wish to apply for a scholarship, also motivate why you need a scholarship.

Application form ITP 2015 - p. 4 of 5

8. Medical statement
Are the below 3 statements applicable to you:

yes /

no

I do not have any infectious diseases or any other illnesses which could present risks to
persons that I will come in contact with.

I do not have any medical conditions which prevent me from carrying out training away
from home

I am in good health and enjoying full working capacity

I hereby declare that all information in the above application statement is true,
Name applicant:

Date:

_________________________________________________________________________
Application procedure:
Please send :
the filled in application form
copies of all obtained higher education diplomas (3.1) and corresponding
transcripts (list of courses and grades) (with English translation)
your employers statement (in English) (4.1)
proof of English proficiency (6)
latest by 12th April 2015 (midnight, Belgian time) to Hasselt University either by:
1. email to nadine.smeyers@uhasselt.be
2. by fax to +32 11 26 91 98, for the attention of Nadine Smeyers

NOTE: NEITHER INCOMPLETE APPLICATIONS, NOR COMPLETE APPLICATIONS

REACHING US AFTER 12th April 2015 CAN BE CONSIDERED FOR ADMISSION!

After the application deadline, all complete files will be reviewed. As soon as the admission
committee will have decided on your application, you will automatically be informed by VLIRUOS / Hasselt University of the outcome (end May 2015).

Application form ITP 2015 - p. 5 of 5