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 - Print Version
 
This is the Print Version of the Application. Please print out this application, complete it and then mail or fax it to the School of Public Health in accordance with the instructions at the bottom of this form.
 
Early Application is encouraged because enrollment is limited.
 
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. If necessary, include additional documents in your mailed or faxed applicaiton to complete your responses to these questions.


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?

Please attach a copy of your resume to this application.

Also please email an electronic copy 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:
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 GHLF email 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
 
Please fax or mail this application, 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
 
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 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.