Sexe - WAPCEH

FORM AFF 1
FICHE AFF 1
NAME:
FACULTY:
FACULTE:
(Surname First)
NOM PRENOMS:
Affix passport
Photograph
SEX:
Sexe:
WEST AFRICAN POSTGRADUATE COLLEGE OF ENVIRONMENTAL HEALTH
COLLEGE OUEST AFRICAIN DES TROISIEME CYCLE DES CADRES DE LA
SANTE ENVIRONNEMENTALE
APPLICATION FOR FELLOWSHIP
DEMANDE D’ADHESION AU COLLEGE
Indicate the Fellowship Applied for:
Indique la classe d’adhesion:
ALL APPLICATION FROMS SHOULD BE ADDRESSED
TOUTES LES DEMANDES SONT Á RENVOYER
TO
Á
THE REGISTRAR/SECRETARY GENERAL,
WEST AFRICAN POSTGRADUATE COLLEGE OF ENVIRONMENTAL HEALTH
Administrative Office: 25, Moremi Street;
Off Aare Avenue, New Bodija, Ibadan, Nigeria.
+234 803 569 6616
1
GENERAL INSTRUCTIONS
INSTRUCTIONS GENERALES
1.
Give your name in full with surname first.
Donnez votre nom suivi de vos prénoms, en toutes lettres
2.
Complete all sections.
Remplissez toutes les sections.
3.
Both sponsors must be fellows of the College. Each sponsor must complete
The recommendation letter and it must be sent directly under separate cover to
Secretary General. It is the responsibility of the applicant to ensure that the
recommendation letters are forwarded to the Secretary-General before the closing date.
Application forms and the recommendation letters received after the closing date will
not be considered for that year.
Les deux parrains doivent-être des membres du collège. Chacun d’eux doit remplir la
fiche de recommandation et la renvoyer directement au Secrétaire Général sous un pli
séparé. Le candidat doit s’assurer que les fiches de recommandation sont renvoyées au
Secrétaire General avant la date de clôture de dépôt de candidature. Les demandes de
candidatures ainsi que les fiches de recommandation reçues après cette date ne
seront pas examinées en vue de l’année en question.
4.
The closing date for all fellowship application by examination is JUNE 30 each year.
La date de clôture de dépôt de toute candidature par l’examen est le 30 juin chaque année.
5.
Application forms must be accompanied by Photostat copies of your certificates. Such
certificates should be listed under item (ix).
Le candidat doit joindre á sa fiche de demande les photocopies de ses diplômes et ces
derniers doivent être inventoriés sous la eu brique ix.
6.
The faculties of the College are:
Les facultés du collège sont les suivantes:
(i) Health Promotion and Environmental Education
(i) Promotion de la santé et l'éducation environnementale
(ii) Environmental Health Audit and Inspection
Audit et inspection de la santé environnementale
(iii) Public Health Entomology and Pest Control
Entomologie appliquée à la santé publique et lutte contre les parasites
(iv) Aviation Hygiene and Sea-Vessels Sanitation
2
Hygiène au niveau du transport aérien et assainissement des navires de mer
(v)
Ecotoxicology
Écotoxicologue
(vi) Bioremediation and Clean Technology
Biorestauration et technologie propre
(vii)
Environmental Epidemiology
Épidémiologie environnementale
(viii) Environmental Health Laboratory, Health Physics and Instrumentation
Laboratoire de la santé environnementale, radioprotection et instrumentation,
(ix) Health Jurisprudence and Environmental Law
Jurisprudence de la santé et droit de l'environnement
(x) Food Hygiene and Safety
Hygiène et sécurité alimentaire
(xi) Municipal and Special Wastes Management
Gestion des déchets spéciaux et de la municipalité
(xii) Environmental Monitoring and Pollution Control
Surveillance et contrôle de la pollution environnementale
(xvi) Population Health and Emergency Management
Santé de la population et gestion des urgences
(7)
All applications should be accompanied by a non-refundable fee of One Hundred US
Dollars or its equivalent.
Le candidat doit joindre à sa demande un droit non remboursable de Cent dollars US ou
équivalent.
(8) All prospective candidates for foundational fellowship, elected fellowship and fellowship
by examinations are seriously requested to download and read a copy of the College
Constitution and understand the eligibility for each class of fellow before completing the
application form.
3
CURRICULUM VITAE
1.
PERSONAL INFORMATION
ETAT CIVIL
1. NAME (Surname First): ___________________________________________________
Nom et Prenoms:
2. PREVIOUS NAME:
Nom Precedent:
____________________________________________________
3. SEX ___________________________________________________________________
Sexe
4. DATE OF BIRTH: _______________________________________________________
Date de Naissance:
5. ADDRESS:
Adresse: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
TELEPHONE:- OFFICE:__________________________________________
Téléphone:
- Bureau: __________________________________________
HOME: __________________________________________
Domicile: __________________________________________
E-mail:
11
__________________________________________
QUALIFICATIONS:
Tires:
A.
(1)
B.
(1)
BASIC QUALIFICATIONS
Formation de base
DEGREE
Diplôme
YEAR
Année
INSTITUTION
Etablissement
__________________
_______
____________________________
__________________
_______
_____________________________
PROFESSIONAL/SPECIALIST QUALIFICATION & DIPLOMAS:
Diplômes et titres professionnels et de spécialiste
DEGREE
Diplôme
YEAR
Année
__________________
_______
INSTITUTION
Etablissement
_____________________________
4
C.
(2)
__________________
_______
_____________________________
(3)
__________________
_______
_____________________________
(4)
__________________
_______
_____________________________
DATES OF PREVIOUS ATTEMPTS OF WAPCEH EXAMINATION
Dates de coup d’e saï précédent d’examen de WAPCEH
________________________________________________________________
III.
PROFESSIONAL TRAINING PROGRAMME:
Programme de Formation Professionnelle:
DATES
IV.
V.
(1)
_________
POSITION
Poste
____________
INSTITUTION
Etablissement
_________________________
(2)
_________
____________
_________________________
(3)
_________
____________
_________________________
(4)
_________
____________
_________________________
(5)
_________
____________
_________________________
POSITIONS HELD AFTER PROFESSIONAL QUALIFICATION:
Fonctions d’exercees depuis la fin de la formation professionnelle:
POST
Poste
INSTITUTION
Etablissement
DATES
Dates
(1)
_____________
_________________________
_________
(2)
_____________
_________________________
_________
(3)
_____________
_________________________
_________
(4)
_____________
_________________________
_________
(5)
_____________
_________________________
_________
PRESENT APPOINTMENT(S)
Emploi(s) Actuel(s)
POST
Poste
INSTITUTION
Etablissement
DATES
Dates
(1)
_____________
_________________________
_________
(2)
_____________
_________________________
_________
5
(3)
VI.
_________________________
_________
PROFESSIONAL REGISTRATION:
Enregistrement Professioonel:
A.
B.
C.
VII.
_____________
YEAR OF REGISTRATION:
Date d’Enregistrement:
____________________________
COUNTRY OF REGISTRATION:
Pays d’Enregistrement:
_____________________________
REGISTRATION NUMBER:
Numero d’Enregistrement:
____________________________
HAS YOUR NAME EVER BEEN REMOVED FROM ANY
PROFESSIONAL REGISTER OF ANY COUNTRY?
Avez-vous été raye d’un registre professionnel d’un pays quelconque?
YES ________________________
Oui
NO _________________________
Non
IF THE ANSWER TO ABOVE QUESTION IS YES
Si vous repondez dans l’affirmatif
(i)
WHEN WAS YOUR NAME REMOVED?
Quand? ______________________________
(ii)
COUNTRY
Pays
COMMENT
Remarques
__________________________________________________
_________________________________________________
VIII. HONOURS, DISTINCTIONS & MEMBERSHIP OF OTHER
PROFESSIONAL SOCIETIES.
Tires Honorifiques, Distinctions, et autres Associations professionnelles
doit le Candidates est membre:
(1)
__________________________________________________________
(2)
__________________________________________________________
(3)
__________________________________________________________
(4)
__________________________________________________________
(5)
__________________________________________________________
6
(6)
IX.
X.
__________________________________________________________
LIST OF DOCUMENTS ENCLOSED.
Liste des pieces jointes
(1)
__________________________________________________________
(2)
__________________________________________________________
(3)
__________________________________________________________
(4)
__________________________________________________________
(5)
__________________________________________________________
SPONSORS: (TWO FELLOWS OF THE COLLEGE SHOULD SEND
TO THE SECRETARY-GENERAL THEIR RECOMMENDATIONS)
Parrains:
(Deux membres du Collège)
NAME /POST
Nom/poste
(1)
___________________________
ADDRESS
Adresse
_____________________________
______________________________
______________________________
______________________________
(2)
___________________________
______________________________
______________________________
_______________________________
IF ELECTED A FELLOW, I AGREE TO OBSERSE ALL THE RULES OF
THE COLLEGE.
Si j’admis, je suis prêt à observer toutes les règles du Collège.
______________________________________________________________________
DATE
SIGNATURE OF APPLICANT
Signature du Candidat
7
CERTIFICATION BY PROFESSIONAL HEAD OF THE DEPARTMENT / NSTITUTION:
Certification par le chef du département
A. I hereby certify that the above particulars in respect of:
Des informations cites ce – dessous sont corrects.
…………………………………………………………….. are correct.
FULL NAME:……………………………………………
QUALIFICATIONS:……………………………………
SIGNATURE:……………………………………………
Signature
DATE:……………………………………………………
OFFICAL STAMP:
RECOMMENDATION BY FACULTY COMMITTEE:
Recommandation par le comité de la faculté:
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
Signature:………………………………….
Name (nom ):……………………………...
Date:………………………………………..
SECRETARY TO FACULTY COMMITTEE
Secrétaire ampères du comité de la faculté
C.
APPROVAL OF COUNCIL:
Approbation de Conseil:
FULL FELLOW
Membre a plein droit
____________________________________________
REJECTED
Candidature non retenue
____________________________________________
DATE _______________________
8