2000

Name _______________________________ Please attach 2 passport photos here

Country ____________________________

English Language Ability

Please check the appropriate ratings below

            excellent | adequate | poor
Reading        [_]        [_]      [_]
Writing        [_]        [_]      [_]
Speaking       [_]        [_]      [_]
Comprehension  [_]        [_]      [_]

Formal Education -- please list formal education, beginning with secondary school

Secondary ___________________________ Location ___________________________

  Subject _______________________ Degree _______________Year Earned ______

University __________________________ Location ___________________________

  Subject _______________________ Degree _______________Year Earned ______

Other _______________________________ Location ___________________________

  Subject _______________________ Degree _______________Year Earned ______

Current Position and Professional Experience

Describe your current telecommunications/broadcast responsibilities and duties. Also describe your previous telecommunications/broadcast experience, identifying types of telecommunications/broadcast systems with which you have worked.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Funding -- please check the appropriate answers below

1.  My organization will pay for my travel: [_] Yes  [_] No

2.  My organization will pay for my subsistence: [_] Yes  [_] No

3.  I am applying for USTTI support for:   [_] Travel   [_] Subsistence

USTTI financial support is limited. Applicants are strongly encouraged to seek alternative sources of travel and subsistence funding. Please notify USTTI immediately if your funding status changes. Please note that at orientation each participant must pay US$150 insurance and administrative fee for the first course, and US$75 for every subsequent course.

Applicant Signature __________________________________ Date ____/____/____
  A Supervisor's signature, where appropriate, is required by the USTTI.

Supervisor Signature _________________________________ Date ____/____/____

Name of Supervisor ____________________________ Title ____________________

Organization _____________________________________________________________

Telex or Fax  ________________________ Telephone (_____)______-___________

Send application via Airmail or FAX to:

1150 Connecticut Ave., NW
Suite 702
Washington, DC 20036
Fax: 202-785-1930

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