ANNEX I

APPLICATION FORM “Seismic Criteria for Bridge Structures”

Santiago de Chile, September 26 to October 13, 2016

OFFICIAL APPLICATION(Signed and confirmed by the maximum authority of the institution)

COUNTRY, CITY

INSTITUTION NAME

APPLICANT NAME

This organization recommends this application in accordance with the regulations of the Kizuna Project "Human Resource and Disaster Risk Reduction Training Program for Latin America and the Caribbean" according to the summons and the general information. In case of selection, the candidate will be authorized to travel to Chile on the dates determined by the organizers of the course. Upon the applicant’s return, the organization is committed to providing the support necessary for proper implementation and transfer of the knowledge received.

Name of person signing Official stamp

Cargo

Email

Date Signature

PART A: INSTITUCIÓN INFORMATION

1. Profile of the institution

a) Name of the organization

b) Type of organization (mark corresponding choice with an “x”)Government

Academic Private International

Other*

*If you marked “other”, indicate:

c) Organization’s mission

d) Relationship with international cooperation (mark corresponding choice with an “x”)Japan Chile Other

sourcesNone

If there is any cooperation involved, briefly describe its main activities:

2. Objective of the application

a) Describe the strategic objectives of your institution related to the structure of bridges.

b) Briefly describe how the training will support the achievement of the previously mentioned objectives

c) Briefly describe the concrete actions that the institution will develop to achieve and/or complement the aforementioned objectives.

d) Briefly describe the reasons for which the candidate has been selected, referring to: 1) course requirements, 2) position or responsibility in the institution, 3) action plans or others.1

1 In case of presenting more than one candidate, indicate the order of priority in the submittal of documentation to the scholarship platform.

PARTE B: APPLICANT’S INFORMATION

1. Personal information. Surnames*

Names

Nationality

Date of birth

Sex Male Female

Passport No.

Passport expiration date

Home address

City

Contact telephone

Email**

*Provide information as it appears in the passport. ** If selected all information shall be sent to this email. Please provide email which is checked often.

Person to notify in case of emergency:Surnames

Names

Relationship with applicant

Home address

Contact telephone

Email

2. Academic information(University and postgraduate studies only)

Degree obtained Institution Country PeriodFrom Until

Other courses and training Course Institution Country Period

From Until

Have you received scholarships before?

Yes _______ No ________

If you answered yes, indicate: Scholarship Country where studies were

doneProgram taken

3. Professional information

1) Current position

2) Description of duties

3) Professional experiencePosition Institution Country Period

From Until

*Briefly describe duties.

4) Self-evaluation of specific knowledge

PERFIL DE COMPETENCIAS PROFESIONALES Grade

Scale1 to 5

A. Self-evaluation about knowledge in the following contents 1 Tectonics and types of earthquakes

2 Behavior of structures during seismic events.

3 Basic definitions of structural elements, seismic loads, earth pressure, and hydraulic forces. The use of technology to measure the loads affected.

4 Soil liquefaction, determine its conditions and components.

5 Fundamental principles of bridge engineering.

6Policies, criteria, procedures, and methods that provide the necessary conditions for the construction of bridges in Chile.

7Seismic design standards for bridges considering notions such as force, methods and details for modeling the structure.

8 Analysis of damage and repair in bridge structures

9 New technologies in seismic design of bridges, use of isolators and monitoring.

10 Analysis of Chilean and Japanese seismic events with damage to bridge structures, efficient solutions for emergency repair or reconstruction.

11 Use of SAP2000 Software in modeling structures of bridges.

12 Minimum concepts of hydrology and hydraulics for the design of bridges.

13 Formulation and execution of action plans. AVERAGE

Medical History (If you should have any health condition mentioned below, submit medical certificate).

1. Do you currently use any type of medication for the treatment of any medical condition? (Give name of medication and dose).

Name of Medication:______________________ Dose:__________

2. Are you currently pregnant? IMPORTANT NOTE: If an applicant should be pregnant, and for the purpose of minimizing health risks, the following documents are required:

1) Carta de consentimiento en asumir riesgos económicos y físicos,2) Carta de consentimiento del supervisor de la participante3) Carta de acuerdo con la participación en el curso, por parte del médico tratante.

( ) Yes ( ) No Month of pregnancy:__________

3. Are you allergic to any medication or food?

( ) Yes ( ) No

( ) Medication ( ) Food ( ) Other: ______________

Specify:_____________________________

4. Do you have any of the following health conditions:

High blood pressure ( ) Yes ( ) No Observations:________________

Diabetes( ) Yes ( ) No Observations:________________

Breathing problems ( ) Yes ( ) No Observations:________________

Digestive tract problems ( ) Yes ( ) No Observations:________________

5.- Other conditions (especificar si hay información relevante que entregar como restricciones alimenticias, alergias, entre otros).

I hereby certify that I have read the above instructions and I have faithfully delivered the requested information. I understand and agree that an uninformed pre-existing medical condition, may, under my responsibility, result in the early termination of my participation in the course.

NAME DATE SIGNATURE

STATEMENT(Signed by applicant)

I hereby declare that I have read the summons with all instructions and corresponding annexes and that the information provided in this form is true and corresponds to everything requested.

Name Date Signature

I hereby declare that I have oral and written domain of the Spanish language.*(For countries which are not Spanish speaking only)

Name Date Signature

*Attach back up document such as accreditation test if you have one.