1. Application Form of Training
Community Health Promotion Management
Date: August 04-08, 2014
At MEDiCAM Office, Phnom Penh
Name of applicant:……………………………Name in Khmer:…….....................……………Sex: M/F
Organisation:…………………… ………................................................Acronym:.………………………
Date of Birth:..........................................................Marital status: Single Married
Job title:……………………………..................................Based in:....................
e-mail:…………………………….........………………………Phone number:…………………………………..
Educational Background
A- Education record (after Junior High School)
Name of Institution /
School
Year Degree/Diploma Received,
Field of Specializationfrom to
ផផផផផផផ 22c ផផផផផផផផ 594 ផផផផផផផ ផផផផផផ 2 ផផផផផផផផផផផ ផផផផផផផផផផផផផផ
ផផផផផផផផ 855 023 880 291 ផផផផផផ 855 023 880 292
House Nº 22c, Street # 594, Phnom Penh - Cambodia. Phone 855-23-880 291 Fax: 855-23-880 292, E-mail: info@medicam-cambodia.org
2. B. Work Experience:
*Please describe all Health & Development work you have been involved in the past and at present,
including part-time and volunteer work.
Name of Organization Year Position / Role
from To
Signature Applicant
ផផផផផផផ 22c ផផផផផផផផ 594 ផផផផផផផ ផផផផផផ 2 ផផផផផផផផផផផ ផផផផផផផផផផផផផផ
ផផផផផផផផ 855 023 880 291 ផផផផផផ 855 023 880 292
House Nº 22c, Street # 594, Phnom Penh - Cambodia. Phone 855-23-880 291 Fax: 855-23-880 292, E-mail: info@medicam-cambodia.org
