CAMBODIAN HIV/AIDS EDUCATION & CARE ( CHEC )

Personnel Information Form  :

Name : (Ms/Mr) ________________________________________________________________

Date of Birth :   ________________________________________________________________

Title/Position : _________________________________________________________________

Name of Organization : __________________________________________________________

Address of Organization : ________________________________________________________

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Tel : ____________________________________ Fax : ________________________________

E-mail : _______________________________________________________________________

Scopes of work/responsibilities at organization : ______________________________________

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Your HIV/AIDS Background : ____________________________________________________

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Which course/Workshop you would like to attend :_____________________________________

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Date of course/workshop ( please specify ) : __________________________________________

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Thank you for filling the application form.