ETHIOPIAN MANAGEMENT INSTITUTE

Document No:

OF/EMI/IC/047
0rganazation Name:

Individual Management Consultants

Issue No. Page No.
Title:
1 Page 1 of 4
Certification Application Form

N.B Please type

I. GENERAL 3 *4
Photograph
1. Full Name:
2. Gender: Male Female
3. Date of Birth:

4. Address: City: sub city:

woreda : Kebele:

Mobile: Tel.

P.O. Box Email

5. Employer/Organization:

II . Education, Experience and Activities

1. EDUCATION (State Field of Study)
 1st Degree in from to
 2nd Degree in from to
 PhD or Equivalent from to

2. WORK EXPERIENCE
No Position Organization Years Duration

ACTUAL WORK ACCOMPLISHED

PLEASE MAKE SURE THAT THIS IS THE CORRECT ISSUE BEFORE USE
 ETHIOPIAN MANAGEMENT INSTITUTE
Document No:

OF/EMI/IC/047
0rganazation Name:

Individual Management Consultants

Issue No. Page No.
Title:
1 Page 2 of 4
Certification Application Form

1. STATE TRAINING SESSIONS YOU HAVE

CONDUCTED
CONTACT PERSON
TOPIC HOURS LEVEL OF TRAINEES (Name and Tel. No.)
No.

CONFIRMATION DOCUMENT CONTACT

2.
LIST CONSULTANCY ASSIGNMENTS YOU HAVE LETTER
No. UNDERTAKEN INCLUDED INDLUDED PERSON
TYPES OF ORGANIZATION DURATION YEAR (PUT/) (PUT/) (Name and
Tel. No.)
ASSIGNMENT

CONFIRMATION DOCUMENT CONTACT

3. LIST RESEARCH ACTIVITIES YOU HAVE LETTER
UNDERTAKEN INCLUDED INDLUDED PERSON
(PUT/) (PUT/) (Name and Tel.
No.)

PLEASE MAKE SURE THAT THIS IS THE CORRECT ISSUE BEFORE USE
 ETHIOPIAN MANAGEMENT INSTITUTE
Document No:

OF/EMI/IC/047
0rganazation Name:

Individual Management Consultants

Issue No. Page No.
Title:
1 Page 3 of 4
Certification Application Form

No.

RESEARCH TITLE SPONSOR DURATION YEAR

4. SHORT-TERM/SPECIALIZED TRAININGS ATTENDED

No. Course Title INSTITUTION FROM TO CERTIFICATE /CONFIRMATION

LETTER INDLUDED (PUT/)

5. PUBLICATION

__________________

6. REFERENCES (List three persons, not related to you, but who are familiar with you)

PLEASE MAKE SURE THAT THIS IS THE CORRECT ISSUE BEFORE USE
 ETHIOPIAN MANAGEMENT INSTITUTE
Document No:

OF/EMI/IC/047
0rganazation Name:

Individual Management Consultants

Issue No. Page No.
Title:
1 Page 4 of 4
Certification Application Form

1. Name Position
Organization

Address

2. Name Position

Organization

Address

3. Name Position

Organization

Address

7. SPECIALIZED BUSINESS AREAS INTEREST WITHIN MANAGEMENT CONSULTANCY SERVICES

(Please state the type of management consultancy you would like to be considered for)

______________________________

8. I hereby confirm that the statements I made above are true and correct.

Signature Date

PLEASE MAKE SURE THAT THIS IS THE CORRECT ISSUE BEFORE USE