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NTC Application Form
CFO application form for need for training certificate
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
EXCHANGE VISITORS PROGRAM COMMITTEE
Manila, Philippines
2 X 2 I.D.
PICTURE
APPLICATION FOR “NEED FOR TRAINING” CERTIFICATE
Form 0 1NTC95
REF. NO.
NOTE:
Please type or write legibly. Use additional papers if necessary. Please do not leave any blanks or questions
PERSONAL DATA:
NAME _______________________ _________________________ _________________
(Last)
(First)
(Middle)
DATE OF BIRTH 31/Dec/2001
(Day/Month/Year )
SEX :
Male
Female
PLACE OF BIRTH ___________________ __________________
(Town)
(Province)
NATIONALITY ___________________ CITIZENSHIP __________________________ RELIGION ______________________
CIVIL STATUS
Single
Married
Widowed
Separated
Divorced
NAME OF ____________________ _____________ _________________NATIONALITY _________________ CITIZENSHIP ____________
SPOUSE
(Last)
(First)
(Middle)
CHILDREN (If any)
NAME
______________________________
______________________________
______________________________
DATE OF BIRTH
________________________
________________________
________________________
ARE YOU UNDER PETITION?
BY WHOM? _____________________ RELATIONSHIP ______________________
YES
IS YOUR SPOUSE UNDE PETITION
NO
YES
NO
ANY OF YOUR CHILDREN UNDER PETITION?
PLACE OF BIRTH
______________________
______________________
______________________
BY WHOM? ___________________ RELATIONSHIP ________________________
YES
NO BY WHOM? ______________________ RELATIONSHIP ____________
PHIL HOME ADDRESS _______________________________________________ TEL NO. _________
____________________________________________ FAX NO. __________
US ADDRESS ______________________________________ FAX NO. __________
_______________________ FAX NO. __________
IMMEDIATE RELATIVE IN THE PHILIPPINES:
NAME ________________________________________ RELATIONSHIP __________________________
ADDRESS ________________________________ TEL. NO. __________
EDUCATONAL BACKGROUND:
SCHOOL GRADUATED (COLLEGE LEVEL) ___________________________________________ TEL. NO. __________
DEGREE OBTAINED ___________________________________
SCHOOL GRADUATED (POST-GRADUATE) __________________________________ TEL. NO. __________
HIGHEST DEGREE OBTAINED ____________________________________
FOR MEDICAL PROFESSION ONLY:
PLACE OF INTERNSIP _________________________________ YEAR OF INTERNSHIP ____
TRAINING/SCHOLARSHIP GRANT
INCLUSIVE YEAR
________________________________________
________________________________________
________________________________________
____________________
____________________
____________________
PROFESSIONAL LICENSES/BOARD CERTIFICATES/ELIGIBILITIES
YEAR OBTAINED
________________________________________
________________________________________
________________________________________
DATE OF
12/31/2001
12/31/2001
12/31/2001
EMPLOYMENT DATA:
PRESENT POSITION/OCCUPATION _______________________________ PERIOD OF EMPLOYMENT: FROM 12/31/2001 TO 12/31/2001
NAME AND COMPANY OF PRESENT EMPLOYER __________________________________________ TEL. NO.
ADDRESS OF PRESENT EMPLOYER _____________________ FAX NO.
BRIEF DESCRIPTION OF WORK _______________________________________
DO YOU HAVE ANY PENDING ADMINISTRATIVE/CRIMINAL CASE?
____________________
_________________________________________
YES
NO
IF YES, GIVE PARTICULARS
REQUEST FOR THE “NEED FOR TRAINING CERTIFICATE”:
INTENDED SPECIALIZATION OF TRAINING ________________________ PERIOD OF TRAINING: FROM 12/31/2001 TO 12/31/2001
PLACE OF TRAINING ________________________________________
ARE YOU A PREVIOUS EVP PARTICIPANTS?
YES
NO
INCLUSIVE DATES:
HOW WILL YOUR EVP FINANCED: (indicate sponsoring agency and attch supporting documents including course outline/brochure)
GOVERNMENT FINANCED ___________________________________
PERSONALLY FINANCED _____________________________________
NON-GOVERNMENTORGANIZED FINANCED _______________________________________
REASON FOR TRAINING _____________________________________
Job Preferences and rank each item:
Government
Educational
Research
Administrative
Private Practice
Manufacturing
Service
Others
I hereby declare under penalties of perjury that the answers given above are true and correct to the best of my knowledge and belief.
I, _________________________________ hereby agree to comply with the two-year home residency requirement of the Exchange
Visitor’s Program (EVP) and shall not seek under any circumstances a waiver of this requirement. As part of the EVP, I also commit to practice in
the specialty as to which I was trained for.
Date:
Signature of Participant: ____________________
NOTE:
1.
2.
Application Form should be accomplished in six (6) copies.
Documents coming from the United States should be authenticated by the Philippine Embassy/Consulate.
ENCLOSURE:
1. Certification of appointment for Acceptance from the university or training Institution in the U.S.
2. Valid Certificate of registration and Professional License from PRC.
