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Ministry of Foreign Affairs

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Thailand International Development Cooperation Agency (TICA)
962 Krung Kasem Road, Bangkok 10100, Thailand
Tel. (662) 280 0980, 2821302 Fax (662) 280 1248, 282 8798
Email: tica@mfa.go.th Website: www.mfa.go.th
FELLOWSHIP APPLICATION FORM

INSTRUCTIONS
This application form is composed of five parts (part A to part E) and should be
completed in triplicate. Part A to part D should be completed by the candidate
(PIease attach
and part E by the government authority in typewritten formo Each question
must be answered clearly and completely. Detailed answers are required photograph here)
in order to make thc most appropriate arrangements. Official authority of
the nominating Government wiIl then forward three copies of the certified
applkation forms to the Thailand Intemational Development Cooperation
Agency (TICA), 962 Kmng Kasem Road, Bangkok 10100, Thailand, through
the Royal Thai Embassy in the nominating country. The nominee is required to
attach medical report or health status certification.
Course Name:
..,......................................................................................".................................................................................................,.................................,........
A. PERSONAL HISTORY
Title Family name Middle name Given name Sex
(as shown in passport)
O Mr. O Male
O M:rs. O Female
O Ms.
City and country ofbirth N ationality Date ofbirth Age Marital Religion
(DD/MM/YY) Status
I

Work address (Please complete this section as clear as Home address (Please complete this section as cIear as
possible, information will be used for travel arrangements.) possible, information will be used for travel
arrangements.)

Fax No : (Country Code I Telephone No : Telephone No :

Area Code I Number)
International AirportlCity for departure :

Email address:
Nameand address ofperson to be notified in case ofemergency:

Telephone No : Relationship ofthis person to yau :

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