DIAC 40 - Young Practitioners Group
Application Form
Title:
*
Dr.
Mr.
Mrs.
Ms.
Miss.
Other(please state)
Full Name:
*
Date of Birth:
*
Nationality:
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Afghanistan
Albania
Algeria
American
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet Island
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guyana
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guatemala
Guinea
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kuwait
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestine
Panama
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Lucia
Samoa
Saudi Arabia
Senegal
Seychelles
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Venezuela
Vietnam
Yemen
Yugoslavia
Zaire
Zimbabwe
Personal address:
P.O.Box:
Post Code:
City:
Country:
Telephone:
Fax:
Mobile:
Email:
Business address:
P.O.Box:
Post Code:
City:
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Country:
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Telephone:
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Fax:
Mobile:
Email:
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Website:
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Please indicate preferred method of communication:
Business
Personal
Please select one:
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Fax
Post
E-mail
Working Hours:(
please include days of week and office hours
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Academic qualification(s):
ID
Degree
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Dates obtained
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Institution Name
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Location
*
*
Languages:
ID
Languages
*
% written
*
% spoken
*