Global Health Leadership Forum
 
Total Program
Please check: Berkeley, CA: January 11 – 17, 2009 and Barcelona, Spain: June 28 - July 4, 2009
 
One Session Only
Please check: Berkeley, CA: January 11 - 17, 2009
Please check: Barcelona, Spain: June 28 – July 4, 2009
 
Application
 
Early Application is encouraged because enrollment is limited.
 
You should submit this form online for timely review by the application committee. To submit online, complete this form, then click the Submit button at the bottom of the form. If you cannot submit the application online, please click here for an application that can be printed out and faxed or mailed.
 
Contact Information
 
Telephone: 1.510.642.1631
Facsimile: 1.510.642.7658
E-mail: ghlf@berkeley.edu
 
Participant Information
(Items marked with * are required)
 
Preferred Title:
First Name*
Last Name*
Title or Position*
Company/Organization*
Division (if applicable)
Address (Line 1) *
Address (Line 2)
City*
State/Province*
Zip/Postal Code*
Country*
Telephone*
Mobile Phone
Fax
E-Mail Address*
Assistant's e-mail (if applicable)
Country of Citizenship*
   
The contact information provided
above is for *		 Home Business Other
   
Highest Level of Education Completed:
University:

Degree(s):
Year Graduated:
 
 

Applicant's Professional Profile *
Please fill out all of the questions in this section.

What are your major responsibilities in your current position?

What are you personal objectives for attending this program?

What business outcomes do you want to achieve as a result of attending this program?

You may copy and paste your resume here (or if you prefer, send an electronic copy of your resume to ghlf@berkeley.edu):
 
English Language Ability
 

English is my native language

My previous training has been in English

Other. Explain:

 
Financial Support *
 

My employer (company/country) will be paying

I will be paying

I will be sponsored. Amount of Sponsor's Commitment: US$

 
Payment Method - Important *
 
Please indicate below the method of payment BEFORE submitting this application.
I wish to make payment by:
 

Wire Transfer

Bank Check
 
Payer Information *
 
Name of Organization
Contact Person
Street Address
City, Zip Code, Country
Telephone
Fax
E-mail
 
References
 
Please identify two references who will attest to your professional experience and English language ability. We will contact you beforehand if we are going to contact your references.
 
First Name
Telephone
E-Mail
   
Second Name
Telephone
E-Mail
 
How Did You Hear About This Program? (answer required)
 

Received Brochure from:

Received a GHLF e-mail, from whom:

A colleague. His/Her name:

Professional Association:

Advertisement in:

Through Internet search, found using:

Other, please explain:

 
For Questions About Course Content
 

Please e-mail Program Director Meg A. Kellogg at ghlf@berkeley.edu.

Forum Website Address: http://ahlf.berkeley.edu
 
Program Policies
 
  • All applications are handled in accordance with the University of California's privacy statement.
  • A complete registration is required for acceptance.
  • Applicants seeking acceptance into the program will be notified by e-mail.
 

Cancellation Policy
 
Written notification of cancellation or substitution must be received from the participant by the calendar day stated below.
 
  • If an applicant withdraws after being invoiced for enrollment more that 30 calendar days prior to the start of the program, the sponsoring organization is entitled to an 80% refund.
  • If an applicant withdraws 30-15 calendar days prior to the start of the program, the organization is entitled to a 50% refund.
  • No refunds are allowed if an applicant withdraws within 14 calendar days of the start of the program.
  • If the participant is unable to attend a program, the sponsoring organization may suggest an alternate and submit app materials for the alternate no later that 7 days prior to the start of the program.
  • No refunds are given for any used portion of the program.
  • A $100.00 fee will be assessed for all returned checks.
 
To Submit Your Application
 
You should submit your application by clicking the Submit Application button below, or if necessary you can print out this form and fax it or mail it, along with your resume to:
 

Global Health Leadership Forum
School of Public Health

University of California, Berkeley

50 University Hall, #7360

Berkeley, CA 94720-7360
Attn: Meg A. Kellogg
 
Fax Number: 1.510.642.7658
 
When you click Submit, your data will be automatically transmitted to the School of Public Health. If your application is reviewed and accepted, you will receive a confirming e-mail and instructions about how to complete your payment in accordance with the payment option that you selected above
 
 
The University of California, Berkeley and Cambridge University do not discriminate in the admission of participants on the basis of race, religion, gender, national origin or handicap. Application by women and members of minority groups is strongly encouraged.