WHC.WHC.DNNPages

Application Form

Section 1: Delegate Information

Title

Identification number (SA ID number/ Passport number)

First Name

Last Name

Preferred name on name badge

Institution

Department

Telephone

Mobile (Please include country code)

Email Address

Address

Address 1

Address 2

City

Postal Code

Country

Emergency Contact

Name

Telephone Number (Please include country code)

Section 2: Education details

University/ school	Year of registration	Graduation year	Field of study (e.g. epidemiology, infectious diseases)	Qualification (e.g. BSc, MBBCH)

No education details added

Section 3: Work experience

Name of institution/ company	Country of employment	Year employment initiated	Year employment terminated/ ‘ongoing’	Job title

No work experience added

Section 4: Details of current supervisor/ director/ head of institute

Name & Surname

Name of institution

Position

Work address

Tel #

E-mail

Section 5: Experience in vaccinology/ immunization

A. Vaccinology-related past experience and present activities

Please indicate, with details, your most important vaccinology-related past experience and present activities. Give details on your present or future responsibilities with particular emphasis on what relates to vaccines or vaccination strategies. This information will be essential during the selection process. (max 500 words)

B. Previous vaccinology training courses

Have you attended any vaccinology training courses?

Name of course	Date of course attendance (year)	Duration (days)	Location of course

No previous vaccinology training details added

Section 6

Please describe your decision-making responsibility in the field of vaccine development, research, vaccination strategies or introduction of new vaccines into public health programs (max 150 words)

Section 7

How will this course have an impact on (i) your professional career, (ii) your institution and (iii) your country/ region? Indicate why you want to attend this course? (max 200 words)

Section 8

List of your most relevant publications in ISSN accredited journals with authors, title and complete reference (Max 15)

Section 9

List of your most relevant presentations with authors, title and complete reference (Max 15)

Required Documents

Passport/ ID

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Letter of motivation written by applicant

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Reference/ letter of recommendation written by line manager/ employer (or similar), confirming support of application

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Full CV including publications (if any)

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