APPLICATION FORM International Workshop on Healthcare in the 21st Century: Importance of Interoperability

12-14th September, 2011

Venue: COMSTECH, 33-Costitution Avenue, G-5/2, Islamabad, Pakistan http://www.youtube.com/watch?v=PQ8sr_9NyHY&feature=related

4 Personal information
1. Passport size scanned Photo

2. Name First 3. Contact Details Telephone

Middle

Last

Fax

E-mail

Home address

Correspondence address (if different from home address)

4. Other Details Nationality Date of Birth Gender Male Female Title Prof./Dr./Mr./Mrs./Ms .

5. Fathers Name ______________________________ 6. Passport Details* Passport Number Date of Expiry Date of Issue Issuing Authority Place of Issue

* If you are from Pakistan please skip point number 6.

5 Employment Details
7. Present or position

Organization Name

From

To

Job Title

Responsibilities

8. Previous positions Organization From Name

To

Job Title

Responsibilities

9. How will this workshop help you in your current work (maximum 200 words)

6 Education
10. Education (start with the most recent) Institutions Name Country Degree Field of Study From To

11. English Language Proficiency Reading Good Writing Very Good Weak Weak Good Good Very

Speaking Good Listening Good

Weak Weak

Good Good

Very Very

7 Research
12. Research interests

8 Training Courses/Workshops/Seminars
13. If, attended any relevant training course/workshop/seminar list those starting with the most recent. City & Topic Organized by Country From To

9 Any additional information to support your suitability

(maximum 300 words)

10 How did you hear about this workshop?

Newsletter Website

Email or letter Friends or family Specify if any other __________________________________

Last Date for Applications August 24, 2011 August 29, 2011
for foreign candidates for candidates from Pakistan

Please send your application (preferably through email) to the following address: Programme Manager COMSTECH Secretariat, 33-Constitution Avenue, G-5/2, Islamabad-4400, Pakistan
Telephone:0092 51 9220681-3 Fax: 0092 51 9211115/9220265/9205264 Email: hanifa@comstech.org; comstech@comstech.org

Note:

11 Language of the Workshop will be English.

12 COMSTECH does not offer travel grants. 13 Applicants who are not officially nominated are required to submit a recommendation letter/No Objection Certificate (NOC) from the head of organization along with the application form. 14 Mentioning title of the workshop in the subject of your email/letter is essential; otherwise your email/letter is likely to go un-responded.