For CDCE office use: (Do not write in)

Application #:

Shortlist #:

APPLICATION FORM FOR THE

CERTIFICATE PROGRAM IN COMMUNITY DEVELOPMENT AND

CIVIC EMPOWERMENT (CDCE)
Faculty of Social Sciences
Chiang Mai University, Chiang Mai, Thailand
Program Dates: September 22 December 21, 2014
Application Deadline: July 10, 2014
Please submit your completed application, essays, passport or NRC copy, photo, and two
recommendations by July 10, 2014 to cdceprogram@gmail.com.
Please paste a passportsize photo of yourself
here (2 inches by 2
inches) and scan with
high resolution.

Name (spelled as it appears on your Passport or NRC): ....

.
Nickname(s):

Date of Birth: ......

Sex: M / F ..

Age: ....

Nationality: . Ethnicity:
... Religion: ..
Marital Status:

Single

Married

Divorced

Widowed

Personal Contact Information:

Address: ...

Telephone:

Is this phone number care of (c/o)? Yes

No

Email: ...........
Do you currently have a VALID passport? (This is not a qualification)
Yes

No

In the process of applying

In the process of extending

If yes or if extending, please write your passport number here: ...

Please also send a copy of your passport photo page with this application (and extension page, if
applicable)
If you do not have a passport, attach a copy of your NRC notary with this application.

Languages: Please rate your language skills on a scale of B=Beginner, I=Intermediate, A=Advanced, F=Fluent
Language
English

Reading

Writing

Speaking

Listening

Burmese
Other:
Other:

Work Experience/History
Where are you currently working? (Name of Organization)
...
Work Address:
.......
...
.
Organization Email: . Organization Website: ..
Job Title (Position): .............
Responsibilities/Duties: ......................
.........................................................................
How long have you worked here? .....
How many hours per week do you spend working at this position? ....
Organizational Profile: (Please tell us about the background, mission and activities of your organization.
(maximum 100 words.)

What other jobs do you have now or did you have in the past?
Job title: Organization: .
Location: Dates: ............
Responsibilities/Duties: .....

......
Job title: Organization: .
Location: Dates: ...............
Responsibilities/Duties: ....
...
Education
Highest Education Level Attained: ..
What schools have you attended?
Name: Location: Dates: ....
Name: Location: Dates: ....
What trainings or workshops have you attended?
1. Name of Training:....
Organized by: ........ Location:Dates: ....
2. Name of Training:.....
Organized by: ........ Location:Dates: ....
3. Name of Training:....
Organized by: ........ Location:Dates: ....
4. Name of Training:....
Organized by: ........ Location:Dates: ....

Specific Skills and Interests

From the list below, which are the TOP 3 issues and approaches that interest you most?
Poverty Reduction
Interfaith
Microcredit
Media
Health
MSM

Project Design
Advocacy
Training
Gender
Agriculture
Migration

Education
Environment
HIV/AIDS
Research
Disabilities
Youth

Peacebuilding
Economic Development
Local Governance
Other __________________

Have you ever been involved in a training program as a curriculum designer, trainer, support staff or
evaluator?
Yes

No

If yes, please describe your experience in the table below.

Name of Training

How long was the

training? How many
times have you
implemented it?

Location

Responsibilities
Curriculum Designer
Trainer
Support Staff
Evaluator
Other: ..
Curriculum Designer
Trainer
Support Staff
Evaluator
Other: ..
Curriculum Designer
Trainer
Support Staff
Evaluator
Other: ..
Curriculum Designer
Trainer
Support Staff
Evaluator
Other: ..

Do you have an experience with advocacy?

Yes

No

If yes, please briefly explain below:

Have you ever been involved in any research projects, assessments, monitoring or evaluation
processes as a research designer, numerator, data analyst or report writer?
Yes

No

If yes, please describe your experience in the table below.

Research Topic

Who initiated and

implemented this
research

Location

Responsibilities
Research Designer
Numerator
Data Analysts
Report Writer
Other: ..
Research Designer
Numerator
Data Analysts
Report Writer
Other: ..
Research Designer
Numerator
Data Analysts
Report Writer
Other: ..
Research Designer
Numerator
Data Analysts
Report Writer
Other: ..

Recommendations
Names of and information about the people writing your recommendation letters:
1. Name:
Organization: Position: ...
Address:
Email Telephone:
2. Name:
Organization: Position: ...
Address:
Email Telephone:
If possible, please have your recommenders send the separate recommendation form directly to
cdceprogram@gmail.com

Applicant Essay Questions

Answer the following essay questions to the best of your ability. Please follow the word limits carefully.

1. Please describe your previous experience in community development activities? (Maximum 500
words)
2. Why are you interested in this program? After finishing the CDCE program, what do you hope to be
able to do? What improvements do you want to make in your organization and community? Detailed
answered are appreciated. (Maximum 500 words)
3. In your opinion, how is your personal work connected to or helping with the democratic transition
that is taking place in Myanmar at this time? (Maximum 500 words)
4. Imagine one of the communities that you know well. What important message would you like to
share with them to improve their lives? How would you plan to share it? (Maximum 300 words)
5. Please give an example of a time when you faced a difficulty in your work. What was the situation?
How did you solve or deal with that difficulty? (Maximum 300 words).

I certify that I wrote these essays and application form by myself.

Signed _____________________________________________

Date ___________

Please send your completed application to: cdceprogram@gmail.com

Application Deadline is July 10, 2014

CDCE Training Program: September 22 December 21, 2014

(APPLICATION DEADLINE is July 10, 2014)
RECOMMENDATION FOR
(Name of Applicant)

SECTION 1:
Your name: .....
Name of organization: ....
Responsibility within the organization: ..........
SECTION 2:
Please answer the following questions:
How long have you known the applicant? ..
Please explain your relationship to the applicant: ....

Please comment on what features/characteristics of the applicant will enable him/her to successfully
study at an intensive course, in Thailand, focused on community development.

Please comment on the applicants ability to use his or her knowledge about community development
and civic empowerment in the future. NOTE: If you are the supervisor of this applicant, please explain
in detail the plans that your organization has for this individual upon his/her return to your organization.
...

SECTION 3:
Please give an assessment of the applicants skills and abilities in the following areas. Rate the applicant
on a scale of 1 to 5. Note: 1 = Poor; 2 = Fair; 3 = Good; 4 = Very Good; 5 = Excellent; ? = Not sure
Applicants ability to live independently and take care of him/herself

(.)

Applicants ability to undertake serious and intensive study

(.)

Applicants tolerance of diversity in terms of race, religion, gender, etc.

(.)

Ability of applicant to foster friendly and respectful relations with others

(.)

Ability of applicant to apply knowledge and skills to real-life situations

(.)

Ability of applicant to communicate openly and reasonably

(.)

Ability of the applicant to working in team settings

(.)

Applicants commitment to doing community development work

(.)

Applicants level of experience working at the grassroots level

(.)

Applicants ability to communicate in the English language

(.)

Applicants ability to advocate or share information with a broad audience

(.)

Applicants potential for doing research

(.)

Applicants potential to be a trainer

(.)

Please use the following space to make any other relevant comments about the applicant:
.
.
I, __________________________________, certify that ________________________________________
(Your Name)

is a: (chose one)

ideal

(Name of Applicant)

strong

satisfactory

not fully qualified

candidate for admission into the CDCE Program.

Signed: Date:
Please return the completed recommendation form directly to cdceprogram@gmail.com
9

CDCE Training Program: September 22 December 21, 2014

(APPLICATION DEADLINE is July 10, 2014)

RECOMMENDATION FOR
(Name of Applicant)

SECTION 1:
Your name: .....
Name of organization: ....
Responsibility within the organization: ..........
SECTION 2:
Please answer the following questions:
How long have you known the applicant? ..
Please explain your relationship to the applicant: ....

Please comment on what features/characteristics of the applicant will enable him/her to successfully
study at an intensive course, in Thailand, focused on community development.

Please comment on the applicants ability to use his or her knowledge about community development
and civic empowerment in the future. NOTE: If you are the supervisor of this applicant, please explain
in detail the plans that your organization has for this individual upon his/her return to your organization.
...

10

SECTION 3:
Please give an assessment of the applicants skills and abilities in the following areas. Rate the applicant
on a scale of 1 to 5. Note: 1 = Poor; 2 = Fair; 3 = Good; 4 = Very Good; 5 = Excellent; ? = Not sure
Applicants ability to live independently and take care of him/herself

(.)

Applicants ability to undertake serious and intensive study

(.)

Applicants tolerance of diversity in terms of race, religion, gender, etc.

(.)

Ability of applicant to foster friendly and respectful relations with others

(.)

Ability of applicant to apply knowledge and skills to real-life situations

(.)

Ability of applicant to communicate openly and reasonably

(.)

Ability of the applicant to working in team settings

(.)

Applicants commitment to doing community development work

(.)

Applicants level of experience working at the grassroots level

(.)

Applicants ability to communicate in the English language

(.)

Applicants ability to advocate or share information with a broad audience

(.)

Applicants potential for doing research

(.)

Applicants potential to be a trainer

(.)

Please use the following space to make any other relevant comments about the applicant:
.
.
.
I, __________________________________, certify that ________________________________________
(Your Name)

is a: (chose one)

ideal

(Name of Applicant)

strong

satisfactory

not fully qualified

candidate for admission into the CDCE Program.

Signed: Date:
11

Please return the completed recommendation form directly to cdceprogram@gmail.com.

12