ࡱ> 02)*1` R0bjbjss -$(\\\Pȃ/\ІІІ+++JIٻi$thpE "+ІІ9^8ІІ =І `ײ&@\ Y0%LL0=L=+t++++++///S\///\"dJ MASHAV Centre for International Cooperation Ministry of Foreign Affairs Jerusalem Dear Applicant, We are pleased that you are applying for a study program in Israel. In order for us to consider your application, please complete the enclosed form (2 copies) and return them to the nearest Israeli representative (embassy or other). Please make sure that all the required information has been provided in detail. Either type your answers or print legibly. This will facilitate the application process and enable us to make our decision in as short a time as possible. You will then be notified by the Israeli representative. Thank you, and we wish you all the best for the future. ESSENTIAL: This application form must be either TYPED OR PRINTED LEGIBLY IN THE LANGUAGE OF THE COURSE, and accompanied by the following: Completed and approved medical certificate form Certificate of language proficiency (If the language of the course/program is not your mother tongue or the official language of your country). Photocopy of the relevant highest academic degree obtained translated to the language of course/program. Three additional passport photographs, apart from those affixed to the two copies of this application. Two letters of recommendation: from present employers or affiliation. These forms should reach the nearest Israeli representative at least ten weeks prior to course/program opening. FOR OFFICIAL USE ONLY. /    __________________   _____________   /: /  /  :______________________________________________ _________________________________________________________________________ _________________ ________________ ____________ ________________      *     "                 ,             . MASHAV- Ministry of Foreign Affairs- Centre for International Cooperation  1. General Name of the course/training program _______________________________ _____________________________________________________________ Name of training institution in Israel ________________________________ Dates: _____________ Language of the course___________________ Financial arrangements: Flight ticket will be paid by__________________________________________________ Tuition and accommodation will be covered by _________________________________ 2. Personal Data Surname_________________________________ Given Names ________________________ Country________________________ Citizenship ________________________ Religion________________________ Passport No. ________________________ Date of Birth_____________ Gender: Male / Female Marital status ____________________ Home address ____________________________________________________________________ ____________________________________________________________________ Telephone (country code______)(area code_______) Number __________________ Fax ___________________ e-mail ____________________________________ 3.Education InstitutePlaceFrom/ToSubjects studiedDegreeSecondary schoolTechnical SchoolVocational schoolAcademic degrees: First Second Third 4.Other studies / courses / seminars ( Last 10 years) Subject of courseCountryOrganized byDuration of studiesYear 5. Previous Studies in Israel Subject of courseYear Training Institute Computer Proficiency No_____ Yes_____ If yes, please specify skills and programs with which you are familiar (word, excel, Qtext, etc.) ________________________________________________________________________________________________________________________________________________________________ 7. Knowledge of languages Mother Tongue____________________________ Other LanguagesReadingSpeakingWritingFairGoodV. GoodFairGoodV. GoodFairGoodV. Good 8 Employment Name of Institution_______________________________________________________________ Address _______________________________________________________________________ Telephone_____________________ Fax :_____________________ e-mail __________________ Type of Institution (please circle): Government / NGO / Private / Other____________________ Present Position _________________________________________________________________ Description of duties _____________________________________________________________ ______________________________________________________________________________ Former place of employment ______________________________________________________ Last position held _______________________________________________________________ 9.Affiliation (if relevant) - Trade Unions/ Cooperatives/ NGOs/ Others Name of organisation _____________________________________________________________ Address _______________________________________________________________________ Telephone__________________ Fax ___________________ E-mail ______________________ Position and/or office held:___________________________ Name of national and/or international organization to which applicant or his organization is affiliated _______________________________________________________________________________ Membership in other organizations: __________________________________________________ 10. References: Please list two people in your country or in Israel, who are acquainted with your professional qualifications NamePositionTelephoneFaxIn your country:In Israel: DECLARATION TRAINING PROGRAM Date__________________ I, the undersigned, Mr./Mrs./Miss of (country)_____________ in submitting my application for study and/or training in Israel as described earlier, declare as follows: I UNDERSTAND that it is the intention of the government of Israel to enable me, if I should be found suitable, to participate in a period of study and/or training in Israel as part of the cooperation between the Government of Israel and my country. I AM FULLY AWARE that the training opportunity given to me is designed for the benefit of my countrys development. I, therefore, pledge to participate fully in all studies offered and to comply with all regulations established by the professional institution hosting the training program. I CLEARLY UNDERSTAND that the purpose of my visit to Israel is to study and/or train. Therefore I will refrain during my stay in Israel from engaging in any political activity and/or gainful employment. I AM FULLY AWARE that my stay in Israel may be discontinued if I should commit any infraction of my undertaking in this declaration, and/or of the Israel civil or criminal law, and/or break the rules and regulations of the school or institute where I will be studying and/or training. I UNDERTAKE to return to my country upon the completion of my studies, as stipulated by the Government of Israel and the supervisors of my training program. I UNDERSTAND that the Government of Israel cannot in any way be held responsible for the material needs of my family during my stay in Israel, nor for my employment upon my return to my country. I AM FULLY AWARE that the legal, financial, and moral responsibility of the Government of Israel ends with the conclusion of the training program. I AM - to the best of my knowledge - of healthy body and mind and do not require any medical treatment or attention. I UNDERTAKE to submit to a further medical examination before or during my studies when required to do so by the Government of Israel. I AM FULLY AWARE that the institute does not bear any responsibility whatsoever for my money, valuables, documents etc. Similarly, the institute bears no responsibility whatsoever for loss of money, valuables, documents, etc. (FOR WOMEN) I AM NOT - to the best of my knowledge - pregnant, and I understand that I am liable to be sent home in case of pregnancy. I UNDERSTAND that the organizers do not accept any responsibility for the treatment of chronic diseases, dental treatment or eye glasses during my stay in Israel. I ALSO UNDERSTAND that my personal belongings are not insured by the organizers. I HEREBY CERTIFY that all information and documents presented are correct and truthful. I AM FULLY AWARE that it is my responsibility to obtain the name and location of the Israeli institute to which I am going, its address and how to arrive there. I UNDERSTAND that all the financial arrangements have been finalized with the Israel Representative before my arrival in Israel. I FULLY UNDERSTAND that, unless stated otherwise, the insurance policy under which I shall be insured by the Israeli institute covers me only during the period of the course/program within the area of the State of Israel. I confirm hereby my full agreement to these conditions. Name and surname of applicant___________________________________________________________ Signature of applicant Date _______________________ Place______________________ Please write a very short autobiography including your expectations from the training program as well as future plans after completion of the program.  MEDICAL CERTIFICATE Surname:Given name (s):Date of birth:Gender:  To be filled out by applicant: Have you/ do you suffer from the following: NoYesIf yes, please specifyAHeart (Cardiovascular)BHypertensionCDiabetesDEpilepsyEMental DisordersFTuberculosisGBronchial AsthmaHVisual DisordersIMalariaJSexually - Transmitted Diseases ( Including AIDS)KMalignant Disorders ( or other tumors)LInternal BleedingMHave you undergone surgical procedures?NHave you undergone medical exams during this year?OAre you currently using any medications?PAre you currently pregnant? If yes, what month? To be filled out by Family Physician/ Practitioner: Has the applicant suffered/ suffering from the following: NoYesIf yes, please specifyAHeart (Cardiovascular)BHypertensionCDiabetesDEpilepsyEMental DisordersFTuberculosisGBronchial AsthmaHVisual DisordersIMalariaJSexually - Transmitted Diseases ( Including AIDS)K\  046Zgpqvw~ʵ~s~~nhh~~~~~~ hECJ hE>*hE5B*\ph hE5\jhEUhEjhE5CJU\hE5CJ\hE5CJZ\^JaJhE5CJZ\^JaJ hEZ^JhE5CJZ\^JhE5>*CJ\hE5CJ\hE5CJ\jhE5CJU\( /N[\lmV W B C | } A q  j  $ & FA$]$ & FA$$A$ $A$^`d d024 $$A$Ifa$ $ & F]$$$A$ $&d A$P L+{vvvvvvvvv$A$Ekd $$Ifl04 laP $$A$Ifa$2kd $$Ifl14 laP +{vlZfgqw $$A$If$A$]$A$F===== $$A$IfkdF $$Iflֈ < & Mpd04 la>{-  F>!!"""#9#{#////K0a0000 111111282446 UhE5CJ\ hECJ hECJZhE5>*CJ\ hECJZ hE>*CJhE5CJ\ hECJ hE5\hEH=kd0 $$Iflֈ < & Mpd04 la $$A$If=kd $$Iflֈ < & Mpd04 la $$A$If=kd $$Iflֈ < & Mpd04 la $$A$If=kd $$Iflֈ < & Mpd04 la $$A$If=kd$$Iflֈ < & Mpd04 la $$A$If>?@ABC $$A$IfCDE{F==00 $$A$If^$3A$]3kd$$Iflֈ < & Mpd04 la3kd$$IflrV yU"5&V }04 lal$ S$A$If]^`S $$A$If^7kd$$IflrV yU"5&V }04 lal$ =S$A$If^`S $$A$If^7kd$$IflrV yU"5&V }04 lal$ =S$A$If^`S $$A$If^7kd$$IflrV yU"5&V }04 lal$ =S$A$If^`S $$A$If^5kd$$IflUrV yU"5&V }04 lal$ =S$A$If^`S $$A$If^7kdy$$IflrV yU"5&V }04 lal$ =S$A$If^`S $$A$If^ $%&'(qkdn$$IflF 5& n&0    4 la $$A$If$A$ ()*+,vvi $x$A$If]x $$A$Ifkd$$IflF 5& n&0    4 la,-/Ddjkznzzzzle\ $$A$If$ $ & FA$^$A$kd$$IflF 5& n&0    4 la Ukdf$$Ifl4\3+% i  04 laf4 $$A$Ifa$ $$A$If   !"#$%&'()*+FfFfr $$A$If+,-./0123456789F>?G$A$Ff|$Ff&! $$A$If>) } ~ !n!o!!!E"F"K"T"^"b" $$A$If$A$b"c"t"u"v"w"x"YPPPPP $$A$Ifkd&$$IflrB% 04 lax"y"z"{"|"}"~"YPPPPP $$A$IfkdP'$$IflrB% 04 la~"""""""YPPPPP $$A$Ifkd($$IflrB% 04 la"""""""##YWWWPKKK$A$$kd($$IflrB% 04 la##$$$&&((h))p**+a,-Y--T../// $r^ra$$ & FrxA$]r^`$ & FrxxA$]r^`$A$///K00 111111f[kd)$$Ifl&&04 la $$A$If$A$^ $r^ra$ $rA$^ra$$rA$]r $r^ra$ 11111>[kd*$$Ifl&&04 la $$A$If[kd0*$$Ifl&&04 la11111>[kd,$$Ifl&&04 la $$A$If[kdh+$$Ifl&&04 la11111>[kd<-$$Ifl&&04 la $$A$If[kd,$$Ifl&&04 la11111>[kdt.$$Ifl&&04 la $$A$If[kd-$$Ifl&&04 la11111>[kd/$$Ifl&&04 la $$A$If[kd/$$Ifl&&04 la11111>[kd0$$Ifl&&04 la $$A$If[kd:0$$Ifl&&04 la11111>[kd1$$Ifl&&04 la $$A$If[kdd1$$Ifl&&04 la11111>[kd*3$$Ifl&&04 la $$A$If[kd2$$Ifl&&04 la11111>[kdb4$$Ifl&&04 la $$A$If[kd3$$Ifl&&04 la11111>[kd5$$Ifl&&04 la $$A$If[kd4$$Ifl&&04 la111112222 $$A$If$A$[kd66$$Ifl&&04 la22292e2i2m22lgg^^^^ $$A$If$A$kd6$$Ifl\<"TTTS 04 la2222222lccccc $$A$Ifkdt7$$Ifl\R]"   04 la2222222YPPPPP $$A$Ifkd28$$IflrR]"  04 la2222222YPPPPP $$A$Ifkd9$$IflrR]"  04 la2222222YPPPPP $$A$Ifkd9$$IflrR]"  04 la2222222YPPPPP $$A$Ifkd:$$IflrR]"  04 la2222222YPPPPP $$A$Ifkd;$$IflrR]"  04 la2223333YPPPPP $$A$IfkdV<$$IflrR]"  04 la333'3(3)3*3YPPPPP $$A$Ifkd*=$$IflrR]"  04 la*3+3-353637383YPPPPP $$A$Ifkd=$$IflrR]"  04 la8393;3m3n3o3p3YPPPPP $$A$Ifkd>$$IflrR]"  04 lap3q3s33333YPPPPP $$A$Ifkd?$$IflrR]"  04 la3333333YPPPPP $$A$Ifkdz@$$IflrR]"  04 la3333333YPPPPP $$A$IfkdNA$$IflrR]"  04 la3334444YPPPPP $$A$Ifkd"B$$IflrR]"  04 la444H4I4J4K4YPPPPP $$A$IfkdB$$IflrR]"  04 laK4L4N4~4444YPPPPP $$A$IfkdC$$IflrR]"  04 la44444445YTTKKKK $$A$If$A$kdD$$IflrR]"  04 la555+5,5-5.5lccccc $$A$IfkdrE$$Ifl\R]"   04 la.5/515>5?5@5A5YPPPPP $$A$Ifkd0F$$IflrR]"  04 laA5B5D5M5N5O5P5YPPPPP $$A$IfkdG$$IflrR]"  04 laP5Q5S5\5]5^5_5YPPPPP $$A$IfkdG$$IflrR]"  04 la_5`5b5s5t5u5v5YPPPPP $$A$IfkdH$$IflrR]"  04 lav5w5y55555YPPPPP $$A$IfkdI$$IflrR]"  04 la5555555YPPPPP $$A$IfkdTJ$$IflrR]"  04 la5555555YPPPPP $$A$Ifkd(K$$IflrR]"  04 la5555555YPPPPP $$A$IfkdK$$IflrR]"  04 la5555555YPPPPP $$A$IfkdL$$IflrR]"  04 la556'()*YPPPPP $$A$IfkdM$$IflrR]"  04 laMalignant Disorders ( or other tumors)LInternal BleedingMUndergone surgical procedures?NUndergone medical exams during this year?OCurrently using any medications?PCurrently pregnant? If yes, what month?QGynecological DisordersPhysical Examination: please specify:NormalAbnormal RBlood pressureSCardiac functionsTRespiratoryULiverVSpleenWLymph NodesXEdema of legsYLab Tests:ESRHB/ HCTWBCHIVUrine GlucoseUrine ProtaneResults:ZPhysician's Conclusions/ General Remarks: Physicians name: Signature:      PAGE  Photo + Three Copies *+-?@ABYPPPPP $$A$IfkdxN$$IflrR]"  04 laBCEdefgYPPPPP $$A$IfkdLO$$IflrR]"  04 laghjYPPPPP $$A$Ifkd P$$IflrR]"  04 laYPPPPP $$A$IfkdP$$IflrR]"  04 laYPPPPP $$A$IfkdQ$$IflrR]"  04 la YPPPPP $$A$IfkdR$$IflrR]"  04 la 29BCYPPPPP $$A$IfkdpS$$IflrR]"  04 la 1289Bcdeghjkmnpqwxyz{|}ºhE5Z\ hE5\ hEZ hE0JZ hE0JjhE0JUjhEUhE hECJhE5CJ\CDFUVWlcccc $$A$IfkdDT$$Ifl\R"04 laWXZlmnlcccc $$A$IfkdU$$Ifl\R"04 lanoq}~lcccc $$A$IfkdU$$Ifl\R"04 lalcccc $$A$Ifkd~V$$Ifl\R"04 lalcccc $$A$Ifkd`abcdB=$A$Ykd]$$Ifl"O#04 la $$A$IfYkd\$$Ifl"O#04 ladfgijlmopyz{|}~$a$$$h&`#$]ha$ $h]h $&`#$$$A$@00 &PPBP/ =!"S#$% (2*2@ 000 &PPBP/ =!"#8$% (2Dd &* <  C Ab: [FX T(lDDn [FX T(lDPNG  IHDR+gAMAPLTEٟ pHYs.&.!^GIDATxMn0ATuv#w!|K/t~!UZHyc338> 4V Ո@eJ:J^?u4bp.#ܬMlbe><1i~6pUƥCIݦN;ի~۝zN. 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