ANNEX I

APPLICATION FORM“Seismic Design Criteria for Bridge Structures”

Santiago de Chile, July 23 to August 03, 2018

OFFICIAL APPLICATION(To be signed and confirmed by the maximum authority of the institution)

COUNTRY AND CITY

NAME OF THE INSTITUTION

This organization recommends completing this application in accordance with the regulations of the Kizuna Project "Disaster Risk Reduction Training Program for Latin America and the Caribbean" according to the call and its corresponding general information. If selected, the applicant shall be authorized to travel to Chile on the dates determined by the organizers of the course. Upon his/her return to their country of origin, the organization is committed to provide the necessary support for an adequate application and transfer of the knowledge received and the implementation of the Action Plan.

NameOfficial stamp

Position

Email

Date Signature and stamp of authorizing supervisor

PART A: INSTITUTION INFORMATION

1. Profile of the institution

a) Name of the organization

b) Type of organization (Place an “x” in the corresponding option)

Government

Academic

Private

International

Others*

*If “other”, please indicate:

c) Organization’s mission

d) Connection with international cooperation (Place an “x” in the corresponding option)

Japan Chile Other sources

None

Should there be another modality of cooperation, briefly describe the institution and the main activities:

2. Objective of the application

a) Describe the strategic objectives of your institution linked to the development of public infrastructure in buildings.

b) Briefly describe how the training will support the achievement of the aforementioned objectives.

c) Briefly describe the specific actions that the institution will develop to achieve and/or complement the aforementioned objectives.

d) Briefly describe the reasons why the candidate has been selected, referring to: 1) course requirements, 2) capacity/position or responsibility in the institution, 3) action plans or others.

PART B: APPLICANT’S INFORMATION

1. Personal information. Surname(s)*

Names

Nationality

Date of birth

Sex Male Female

Passport No.

Expiration date of passport

Private address

City

Contact telephone

Contact email**

*Give information exactly as appears in the passport and attach a copy of the passport to this application.**If selected, all the information will be sent to this email. Please give an email that you check constantly.

Person to notify in case of emergency:

Surname(s) Surname (s)

First name(s) Name

Relationship with applicant Relación con el postulante

Private address Dirección particular

Contact telephone Teléfono de contacto

Email Mail de contacto

2. Academic information (University studies and beyond, only. Please attach respective copies of certificates.)

Institution Country PeriodFrom Until

Other courses and trainings (Attach respective copy of certificates and/or accreditations)

Course Institution Country PeriodFrom Until

Have you received scholarships before?

Yes _______ No ________

If “Yes”, please indicate:

Scholarship Country where studies were done

Program taken

Have you been awarded Jica scholarships before?

Yes _______ No ________

Which one(s)? _______________________

Have you fulfilled your obligations as a JICA scholar?______________________________________

PART B: APPLICANT’S INFORMATION

Professional information

1) Current position

2) Description of functions

3) Professional experience

Position* Institution Country PeriodFrom Until

*Briefly describe functions.

4) Self-evaluation on disaster risk reduction.

Describe your experience in two recent projects on disaster risk reduction in which you have participated.

Self-evaluation according to the knowledge you have about the following contents

GRADEOn scale of 1 to 5

1 Seismic Engineering in Buildings

2 Geotechnical Engineering in Buildings

3 Earthquake-resistant analysis in Buildings

4 Land Survey with auscultation equipment for structures

5 Land Survey with auscultation equipment for soils

6 Static laboratory tests of structures

7 Dynamic laboratory tests of structures

8 Constructive Techniques

9 Structural Inspection of Works

10 Building Repair and Rehabilitation Techniques

11 Theoretical and practical concepts of the post-disaster evaluation of buildings (Buildings and Housing)

12 Application in the field of a Standardized Sheet for the Rapid Post-Earthquake Assessment of Buildings and Housing.

13 Formulation and Execution of Action Plans.

AVERAGE

Medical history (If you should have any of the medical conditions listed below, please attach medical certificate). 1. Do you currently take any medication for the treatment of any medical condition? (Give medication

name and dose).

( ) Yes ( ) No

Medication name:______________________ Dose:__________

2. Are you currently pregnant?IMPORTANT NOTE: In the event that a candidate is pregnant and in order to minimize the risk to their health, it is necessary to attach the following documents:

1) Letter of consent to assume economic and physical risks,2) Letter of consent from the participant's supervisor3) Letter from the attending physician, agreeing to your participation in the course.

( ) Yes ( ) No Month of pregnancy:__________

3. Are you allergic to any medication or food?

( ) Yes ( ) No

( ) Medication ( ) Food ( ) Other: ______________

Specify:_____________________________

4. Do you have any of the following health conditions?

High blood pressure( ) Yes ( ) No Observations:________________

Diabetes( ) Yes ( ) No Observations:________________

Respiratory problems( ) Yes ( ) No Observations:________________

Digestive tract problems( ) Yes ( ) No Observations:________________

5.- Other conditions (specify if there is relevant information to be submitted such as food restrictions, allergies, among others).

I hereby certify that I have read the above instructions and have delivered the information requested in good faith. I understand and accept that a pre-existing uninformed medical condition could, under my responsibility, result in the early termination of my participation in the course.

NAME DATE SIGNATURE

DECLARATION(To be signed by applicant)

I hereby declare that I have read the call with all its instructions and corresponding annexes and that the information provided in this form is completely true and includes all the information requested.

Name Date Signature

I hereby declare to have oral and written knowledge of the Spanish language.*(For non-Spanish-speaking countries only)

Name Date Signature

* Attach supporting document such as accreditation test, if available.