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REGISTRATION FORM

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THE CENTER FOR DEVELOPMENT COMMUNICATION WORKSHOPS

Please select a workshop:

International Executive Media and TV Workshop (IEMTW)

_____ IEMTW: Bangkok, Thailand: December 7-9, 2011 (English)

Strategic
Communications for Good Governance Programming Workshop (SCGGPW)

____ Geneva, Switzerland: TBA (English)

____ Bangkok, Thailand: TBA (English)

Media Management Skills for Senior Staff (MMSSS)

____
SMS: Bangkok, Thailand: December 12-13, 2011 (English)
;ington, DC: October 12-13, 2009 (English)

Last Name:	___________________________________________________________
First Name:	___________________________________________________________
Nationality:	___________________________________________________________
Passport #:	___________________________________________________________
Date of Birth:	___________________________________________________________
Place of Birth:	___________________________________________________________
Gender:	Male:____ Female:____
Organization:	___________________________________________________________
Present Title:	___________________________________________________________
WORK ADDRESS
Street/P.O. Box:	___________________________________________________________
City, State, Zip:	___________________________________________________________
Country:	___________________________________________________________
Phone:	___________________________________________________________
Fax:	___________________________________________________________
E-Mail:	___________________________________________________________
HOME ADDRESS
Street/P.O. Box:	___________________________________________________________
City, State, Zip:	___________________________________________________________
Country:	___________________________________________________________
Phone:	___________________________________________________________
Fax:	___________________________________________________________
E-Mail:	___________________________________________________________
Education:	___________________________________________________________
English Speaking and Writing Ability:(please circle)	Excellent Very Good Good Fair
French Speaking and Writing Ability:(please circle)	Excellent Very Good Good Fair
Course Tuition Fees will be paid by:(please circle)	Sponsoring SelfOrganization

If sponsored, please return Sponsorship Form.

Tuition includes trainer costs, background and course materials, one
hour of individual executive coaching, and all coffee breaks. Fees do
not cover airfare. Participants are responsible for their own travel
arrangements, costs and any visa arrangements. Fees must be paid in US
dollars prior to the start of the workshop. Please see the schedule for
payment deadlines.

100% of the tuition will be refunded up to two (2) weeks before the
workshop begins. After two weeks, there will be no refund, unless cancellation
was necessary due to exceptional circumstances.

Qualified participants who are interested in receiving sponsorship or
financial support can consider contacting the following agencies which
have sponsored participants or participated in CDC training events: USAID
country missions in Amman, Beirut, West Bank, Morocco and Egypt, UNICEF
or UNDP offices, UNFPA, International Fund for Agricultural Development,
or the European Union. Other specialized agencies such as UNRWA may also
send staff or provide sponsorship.

Enrollment at all CDC International Executive Training Workshops is
subject to availability and approval by CDC staff. All applications will
be reviewed by CDC.

I VERIFY THAT ALL STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT.

_____________________________ _________________

Signature Date

Please return the completed form to:

Mr. Moncef M Bouhafa

The Center for Development Communication

PO Box 25228

Washington, DC 20007

USA

Or fax the signed form to: +1 413 702 5694

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Moncef Bouhafa