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Activity title: 2013 Global Flagship Course on Health Systems Strengthening and Sustainable Financing: The Challenge of Universal Health Coverage
Location: Date: 09 December 2013 - 17 December 2013
TTL: Joy Antoinette De Beyer TTL Email: Jdebeyer@worldbank.org
TA: Lydia Ndebele TA Email: lndebele@worldbank.org
Thank you for your interest in this learning activity. To apply, please complete all of this form. (Privacy Information)

1. Applicant

First / given name: *

Last / family name: *


Job title: *

Gender:
 
* Male Female


Age (in years): *
Less than 20 20 to 29 30 to 39 40 to 49 50 to 59 60 and over

2. Applicant's contact information

Organization full name: *

Acronym or
abbreviation:

Department full name: *



Street address: *

P.O. box:


City: *

Postal code:


State/ Province:

Country: *



Email: *

Confirm Email: *

Telephone:


Fax:

Mobile:



3. Applicant's current function: *

Head of State (National Level)
Member of Cabinet
Other Minister / Deputy Minister
Legislator / Parliamentarian
High Court Judge
Head of Subnational / Local Government
Traditional / Community Leader
  Head of Organization
Manager
Professional / Technical Staff / Officer
Professor / Teacher / Trainer / Educator
Administrative / Support Staff
Student
Other

4. Scope of applicant's organization: (location of people served) *

International   National   Subnational / Local

5. Type of organization for which the applicant works: *

Please read all 22 options and click the one that best describes the organization.


Government (country aided by the World Bank) / Regulatory Agency
Central Bank
Law Enforcement Agency
Traditional Authority / Institution
Service / Utility Provider (health care, water, waste management, energy, telecommunications, transport, etc.)
Micro-credit / Micro-insurance
Other Financial Service Company
Farmers' / Workers' Cooperative
Other Private Sector Company
Academic / Training Institution
Research Institute (non-university)
Media
(As applicant's main work)
Labor Union
Political Party
Religious Institution
Association
Other Not-For-Profit Non-Government Organization (NGO) (including service delivery)
World Bank Group
Other Multilateral Government Organization
Bilateral Government Donor
Other Development Financing Entity

6. Additional Applicant's Information *

Applicant's educational attainment: *
Current work responsibilities: *
Reasons for applying / expectations: *
Source of funding (to pay the learning activity's fee):
(Check all that apply)
*
Self-Paid   Employer   Other non-World Bank sponsor, specify:
Comments, if any

7. Agreement *

I certify that all information provided is accurate. I understand that this application will be reviewed and applicants will be selected based on relevant experience and space availability. I also understand that if my participation is subject to clearance by my government or to approval by a particular agency in my country, I will comply with this requirement.


If selected, I understand that my feedback about the learning activity in which I participate can help the World Bank Institute improve its activities in the future. I agree to complete a confidential survey at the end of the learning activity and a few months later if I am asked.

I agree