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Mr Mrs Ms




Administration of the State Member of the ITU




____________________________________________
Last Name




Sector Member of ITU







Partner of ITU

____________________________________________
First Name







Non-Member

Recipient of a grant Yes No







Complete name and address of the administration or the organization:

______________________________________________

Tel.: _______________________________________________

______________________________________________




______________________________________________

Fax:___________________________________________

_________________________________________

E-mail:__________________________________



Arrival date and Flight No:

Arrival time in Algiers:







Departure Date and Flight No:



Departure time from Algiers:






Date: ___________________________

Signature: ______________________________________



- In case of cancellation, please inform us by Fax: +213 21 234014 or E-mail: f.medjahed@arpt.dz ) at least 24 hours in advance

ANNEX 4


(to TSB Circular 213)





ITU Regional Workshop on Bridging the Standardization Gap and
Interactive Training Session
: Simulated Study Group Meeting

(Algiers, Algeria, 26-27 September 2011)



Please return to:

Fellowships Service
ITU/BDT
Geneva (Switzerland)



E-mail : bdtfellowships@itu.int

Tel: +41 22 730 5095

Fax: +41 22 730 5778

Request for a fellowship to be submitted before Monday, 29th August 2011 

Participation of women is encouraged

Country: ……………………………………………………………….………..………………………….......…..

Name of the Administration or Organization: ………...……………….…..………………………………............

Mr. / Ms.: ……………….………………………………….…………………………………………......…….….

(family name) (given name)

Title: ………………………………………………..…………………………….……………………....……..…

Address: …………………………………………………………………………………………………....……...

………………………………………………………..………………………………………………………......…

Tel: ……………………….……. Fax: …………..…….………...

E-Mail: …...………………………………………………………………………………....................................

PASSPORT INFORMATION:

Date of birth: ……………………………. Nationality: ……………………………….………………........……

Passport Number: ……………….…………… Date of issue: ……………………...….………..……............….

In (place): ……………………………….…..… Valid until (date): ………….……………………….......…….


CONDITIONS

  1. One full fellowship per eligible country within the Arab and Africa region only.

  2. It is imperative that fellows be present for the entire duration of their fellowship.



Signature of fellowship candidate: ………………………………………….. Date: ……...……………...



TO VALIDATE FELLOWSHIP REQUEST, NAME AND SIGNATURE OF CERTIFYING OFFICIAL DESIGNATING PARTICIPANT MUST BE COMPLETED BELOW WITH OFFICIAL STAMP.
Signature: ……..………………………………………. Date: ……………………………………………..

______________

ITU-T\BUREAU\CIRC\213R.DOC




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