The Joint

CORAT Africa
And
NPI-Africa
PEACEBUILDING INSTITUTE 2015
(4th 22th May 2015)
APPLICATION FORM FOR COURSES IN CONFLICT
RESOLUTION AND PEACEBUILDING
PART 1: To be Completed by the Applicant
1. Full Name..................................................................................................
Title: .....................................
Rev. /Dr. /Sr. /Bro. /Fr. /Mr. /Mrs. /Miss. etc
Full Name of Spouse (If applicable)
2. Date of Birth.................................

Place of Birth..................

3. Nationality................................................................................................
4. Passport
(a)Number....................................................................................
(b)Date of Issue............................................................................
(c) Expiry Date..............................................................................
(d)Place of Issue...........................................................................

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5. Contact Address
(a)

Permanent Contacts:

Address.............................................................................................
Telephone (include country code).....................................................
Fax No...............................................................................................
E-mail:...............................................................................................
(b)

Current Contacts

Address.............................................................................................
Telephone (include country code).....................................................
Fax No...............................................................................................
6. Education
Name and
the
Institution

Level e.g.
School,
College,
University,
etc

Dates

Examination
Passed e.g.
Certificate,
Diploma,
Degree

Language Proficiency

Langua
ge

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Proficie
ncy
Speakin
g

Proficiency
Reading

7. Employment History
Use extra pages if possible
Position Title

Employers Name and Address

(Point of Contact, Telephone Number and
E-mail Address)

Dates of
Employment
(D/M/Y)

Specific Duties of Present Post (use separate paper if necessary)...........................

.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

8. The Name of Module (s) Applying for.................................................................

9. Briefly State Your Expectation(s) as a Result of this Training:.............................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................

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10. Health and Meals

Do you have any health condition for which we should make special
arrangements before your arrival (e.g. Diabetes, High Blood Pressure, e.t.c)?. .
...........................................................................................................................
...........................................................................................................................
Are you on special diet?..............
NO

YES..................

If Yes, specific so that the administration at the course venue can make advance
preparation
...........................................................................................................................
...........................................................................................................................
Declaration
I hereby declare, by signing herein below, that the information in this application
is correct and complete to the best of my knowledge, and hereby give my
permission to Admission authority to obtain any verification deemed necessary
to process my application.
Signature of Applicant:.......................................................................................
Date:..................................................................................................................
NB: Please, when returning the form, include two recent coloured
passport photos

Part 2: To be filled by the Head of the Nominating

Institution/Organization
1. Name of Nominating Institution/Organization
.......................................................................................................................
.......................................................................................................................
Contacts
Address:.........................................................................................................
Telephone Number:........................................................................................
E-mail Address:..............................................................................................
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Fax Number:...................................................................................................

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2. Nomination:
By signing herein below:
(a) I hereby nominate:..............................................................................
For: (Mention the Course).....................................................................
.............................................................................................................
(b) I will remit a registration fee of 20% of the total costs upon enrolment
(c) I will remit the balance of balance of courses fees in the sum of US$
(Before the commencement of the course)
(d) I agree to provide the return airfares by direct international flight or
meet the overland travel costs to and from Kenya for the candidate
(e) I will provide the candidate with airport departure tax and out-ofpocket allowance to cover incidentals and medical expenses
Name of Person Nominating:..........................................................................
Position in the Institution:...............................................................................
Signature:.......................................................................................................
Date:..............................................................................................................
Note: A hard copy of this registration should be sent to: Attention: Anne Muriuki,
Administrator, NPI-Africa, P. O. BOX 14894-00800, Nairobi, Kenya or faxed to +254
20 4440097. Queries and/or more information can be given on:
Telephone numbers: +254 20 4441444/4440098/+254720988384/+254735765688;
or
E-mail address: info@npi-africa.org or bokok@npi-africa.org

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