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APPENDIX OF APPLICATION FORM
for
Training of Information and Communication Technology
for Visually Impaired Persons

Please submit all pertinent documents and your answers to this questionnaire in typewritten form together with your Fellowship Application Form.
**This appendix is available at http//www.apcdproject.org/trainings/vip04**

Download Application Form for Training of Information and Communication Technology
for Visually Impaired Persons(51 KB)

TITLE Mr. 
Ms. 
Mrs.
Dr. 
GENDER MALE  
FEMALE
NAME (capital letter)

 

 

 

FAMILY NAME GIVEN NAME MIDDLE NAME
BIRTHDAY (Day/Month/Year):
PASSPORT NUMBER:
PASSPORT EXPIRE DATE (Day/Month/Year):
HOME ADDRESS:




TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):


EMAIL ADDRESS:
NAME OF THE ORGANIZATION:



ADDRESS:



TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):


EMAIL ADDRESS:
DISABILITIES (IF ANY)
 
YES
NO
TYPE OF DISABILITIES: Physical Disability
Hearing Disability
Visual Disability
Intellectual Disability
Mental Disability
Other (                  )
USAGE OF ASSISTIVE DEVICES: YES NO
DETAILS OF YOUR ASSISTIVE DEVICES:
  Power/electronic wheelchair ( Wet battery Dry battery)
  Wheelchair
  Crutch (es)
  White cane
  Other ( )
USAGE OF SIGN LANGUAGE (SL):
 English SL  Other SL (                         )
DIETARY REQUIREMENT (IF ANY)

I hereby certify that all the provided information is correct, accurate and complete to the best of my knowledge.

In the event that I suffer injury, illness or death during the course of my participation in the program/course, I shall hold the Royal Thai Government, the Government of Japan, Japan International Cooperation Agency (JICA) and/or the Asia-Pacific Development Center on Disability (APCD) harmless and without any liability whatsoever for compensation towards myself, my legal representatives and/or my heirs. Should I cause any person loss of property, injury, illness or death during the course of my participation in the program/course, I shall be fully responsible and liable for the said person without reference whatsoever to the Royal Thai Government, the Government of Japan, JICA and/or APCD.



SIGNATURE OF NOMINEE...............................


PRINTED NAME OF NOMINEE (                                                  )

DATE:



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QUESTIONNAIRE

Q1. What kind of software or ICT equipment/tools does your organization use to support computer training courses?

 

Q2. In you opinion and experiences in the field, what are the priority needs of ICT for visually impaired persons in your country?

 

Q.3 What skills do you think are necessary to organize/implement ICT training for visually impaired persons?

 




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