Passport photo

Dokters van de Wereld Postbus 16641 1001 RC Amsterdam Tel: 020 465 2866 Fax: 020 463 1775 www.doktersvandewereld.org recruitment@doktersvandewereld.org

Please fill out the application form as fully as possible. Dokters van de Wereld promises to treat this information with respect and privacy. It will not submit the information to a third party without the applicants consent. Please send this application form to the recruitment department at the above mentioned P.O. Box address and e-mail. Please send your application form digital by e-mail and in hardcopy by post including your passport photograph.

SECTION 1 PERSONAL
1.1 Personal details Name: Surname: Address: Postal code and city: Country: Telephone home: Telephone work: Title:

Date and place of birth: Nationality: Sex: Marital status: E-mail: Mobile telephone: Fax:

1.2 Position I apply for the position of: (Doctor, Nurse, Midwife, Logistician, Administrator, Psychologist, Human Rights Specialist, Country/Project/Medical Co-ordinator, Other) I am available from day/month/year to day/month/year: How much time departure notice do you need? Are you willing to work overseas alone? Have you applied to Dokters van de Wereld before? If yes, when? And what was the result of your application?

D/M/Y D/M/Y

Yes / No Yes / No

1.3 Motivation Please write down your motivation to work for Dokters van de Wereld. If you are a non-medical professional, please state why you would like to work for a medical organization. (In total not more than 400 words.) Do you have a preference for work in a certain country or project? Why? In which country or project do you not wish to work? Why?

SECTION 2 EDUCATION
2.1 Education Please list any academic education in chronological order. From To Field of education Institution Qualification achieved

2.2 Specialization Please list any specialization in chronological order. From To Field of specialization Institution Qualification achieved

2.3 Additional training and courses Please list any additional training and course in chronological order. From To Field of training or course Institution Qualification achieved

SECTION 3 EMPLOYMENT EXPERIENCE

3.1 Current situation Are you currently employed? Employer: Job title (main responsibilities): Yes / No

From day/month/year to day/month/year: Do you have experience of at least 6 months working for a NGO? 3.2 Employment history in your own country

D/M/Y D/M/Y Yes / No

Please list any relevant working experience in your own country in chronological order. From To Job title Employer

3.3 Employment history outside your own country Please list any relevant working experience outside your own country in chronological order. From To Job title Employer

3.4 Professional references References are required to support all applications. Please give the name of two professional references. Surname: Organization: Contact address: Surname: Organization: Contact address: Do you give permission to Dokters van de Wereld to contact your references before your interview? Title: Title: Occupation: Telephone: E-mail: Occupation: Telephone: E-mail: Yes / No

SECTION 4 RELEVANT SKILLS AND KNOWLEDGE

4.1 Management Please list any experience you have, professional or otherwise, in management (organizing, planning, supervision, leadership). From To Experience

4.2 Training Please list any experience you have, professional or otherwise, in coaching/training of others. From To Experience

4.3 Languages Mother tongue: Speak Language English French 4.4 Other Please state what computer skills you have: Do you have your driving license? Please list your travel experiences: From To Country, region Type of travel Car / Motor / Truck / No / Other Basic Good Fluent Basic Read Good Fluent Basic Write Good Fluent

Please list any other experience you think is relevant for working with Dokters van de Wereld:

SECTION 5 ADDITIONAL INFORMATION

5.1 Personal information Passport number and country: Passport issue date and place: Passport valid until: Bank or giro account number: Blood type: Eye colour: Hair colour: Height:
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5.2 Contact in case of emergency Name: Surname: Address: Postal code and city: Country: E-mail: 5.3 Recruitment monitoring Please specify how you heard about Dokters van de Wereld: Title:

Relationship: Nationality: Sex: Telephone home: Telephone work: Mobile telephone:

DECLARATION
I declare that to the best of my knowledge the information stated in this form is correct and complete. Date: Place: Signature: