GOVERNMENT OF INDIA

MINISTRY OF EXTERNAL AFFAIRS

INDIAN TECHNICAL AND ECONOMIC COOPERATION ( ITEC ) AND
SPECIAL COMMONWEALTH ASSISTANCE FOR AFRICA PROGRAMME ( SCAAP)
TECHNICAL COOPERATION SCHEME OF COLOMBO PLAN
(Application for the courses fully funded by the Ministry of External Affairs, Government of India)

Please read instructions carefully before applying

APPLICATION FORM

PART- I
Nationality: _Ecuadorian_____

Name of Course: ADVANCE CERTIFICATE

COURSE ON EDUCATIONAL MEDIA
PRODUCTION FOR E- learning
Commencing :
From _27/01/2016____ to 22/03/2016

Institute : NATIONAL INSTITUTE OF

TECHNICAL TEACHERS TRAINIG AN
RESEARCH_

DD/MM/YYYY

DD/MM/YYYY

1. Personal Particulars
Name (s) :

ALFREDO BOLIVAR

Surname :

MURIEL BONILLA

Sex (tick
one):

MALE

Marital
Status:

MARRIED

Date of Birth:

13
- DECEMBER /1972
---------------------------------------------------Date - Month - Year

Passport
No.:

May 15th 2013________________Date

2015______

Address:

& Place of issue :- ____Riobamba___________Valid till :- _May 15th

Office

Residence

Colegio Pedro Vicente Maldonado

PRIMERA CONSTITUYENTE Y
ESPAA
Tel Nos.
Mobile/Cell :
Fax :
2013-14/revised

593 032 961650

593 995 066949
593 032 960211

2 DE AGOSTO 2103 Y 5
JUNIO PRIMER PISO
593032950059
593995577353

E-mail :

[email protected] [email protected]

Special dietary needs, if any :

Person(s) to be notified in case of Emergency

Official Contact

Personal / Family Contact

Name :

KARLA BRAVO
2 DE AGOSTO 2103 Y 5
JUNIO

Address:

Tel No:

593032950059
593983143925

Mobile /Cell :
Fax:
E-mail:

[email protected]

Educational Qualification(s)
Degree / Diploma / Certificates

Year

Name of Educational Institute

MASTER DEGREE IT (Information

Technology)

2010

Bs. Accounting and Audit

2004

TESOL (Teaching English Second

Language)
English Language Instruction

2013

ESCUELA SUPERIOR
POLITECNICA DE
CHIMBORAZO (Ecuador)
ESCUELA SUPERIOR
POLITECNICA DE
CHIMBORAZO (Ecuador)
Kansas State University (USA)

2013

University of Kentucky (USA)

English Second Language/ English

First Language Methods

2013

Culture and Language and

Classroom

2013

IBT TOEFL TEST ETS

2013

KANSAS UNIVERSITY &

UNIVERSITY DE KENTUCKY
(USA)
KANSAS UNIVERSITY &
UNIVERSITY DE KENTUCKY
(USA)
UNITED STATES OF AMERICA

Professional Qualification(s), if any:

Professional Qualification(s)
1
2

Research Director for UEPVM High

School students.
Developer of e-learning class for
accounting and audit at Escuela
Superior Politecnica de Chimborazo
Foreign Language English Teacher

Year

2014 -2015
2010
2013-2015

2. Details of Employment/Profession (current & previous)

2013-14/revised

Name of Institute

UNIDAD EDUCATIVA PEDRO

VICENTE MALDONADO
Escuela Superior Politcnica
de Chimborazo
UNIDAD EDUCATIVA PEDRO
VICENTE MALDONADO

Name of Employer /
Department / Company
1

DOCENTE DE B.G.U
High School Teacher

ESTADISTICA
INFORMATICA, AUDITORIA
INFORMATICA
MATEMATICA

3
4

Position
UNIDAD
EDUCATIVA
PEDRO
VICENTE
MALDONADO

Period

Description of Work

ENERO 7
2014

UNTIL NOW

CEDECORCH

ENERO 2010

DIC -2011

INGLES,ESTADISTICA,
INVESTIGACION

INSTITUTO
TECNOLOGICO
EDUPRAXIS

ENERO -2006

JUNIO- 2006

INGLES, AUDITORIA
INFORMATICA

CEDECORCH

ENERO 2010

ABRIL-2012

Are you an employee of: (Mark appropriate box)

a. Government

c. Private company

b. Semi-government/Parastatal

d. Others ( Please specify)

Details of present employer :

Name :
Address:

UNIDAD EDUCATIVA PEDRO VICENTE MALDONADO

PRIMERA CONSTITUYENTE Y EXPAA
RIOBAMBA, CHIMBORAZO
Ecuador

Tel. No. :
E-mail :

593 032 961650

3. Have you ever attended a course sponsored by the Government of India? (Mark one)

Yes

3.1 If answer to 3 is yes, details of the Course (s):

Name of the Course (s) and Institute
1

Year

TECNOLOGIAS DE LA INFORMACION Y
2014
COMUNICACIN APLICADAS A LA EDUCACION
II EDUC VIRTUAL 1, Ministry of Education of
Ecuador (e-learning applied to education)
INTRODUCCION A LAS TECNOLOGIAS DE LA
2014
INFORMACION Y COMUNICACIN Ed. Virtual 1
y 2 (e-learning applied to education)

4. Details of Course(s) attended, if any, outside your country:

2013-14/revised

No
X

Country

Course Details & Duration

Year

UNITED STATES OF
AMERICA

Teaching English as second language/

May until December 2013

2013

CUBA

INFORMATION TECHNOLOGY
CONVENTION/8 DAYS

2004

Sponsor/Programme
SENESCYT / MINISTRY OF
EDUCATION / GO TEACHER
PROGRAM
ESCUELA SUPERIOR
POLITECNICA AND INSTITUTO
TEGNOLOGICO JOSE ANTONIO
ECHEVERIA CUBA

5. Please describe in your own words (about 100 words) - (a) qualification/experience related to
the course applied for; & (b) reason (s) for applying for this training course.

2013-14/revised

6. Certification of English language proficiency (by Indian Mission/Designated Authority)

Good
Spoken
Written

Basic

Remarks

X
x

Mother tongue / Native language: ___spanish___________ / Other language(s), if

any:_English________________
English Language test administered
by:

CEDECORCH
Centro Ecuatoriano de Computacin y Relaciones
Humanas e Ingls
Acuerdo Ministerial #
Eng. Csar Guala Hurtado

Name :
Address :

Telephone Number:
Email :

Guayaquil y Coln
Riobamba, Ch EC600150
Ecuador
South America
593 329 62 430

------------------------Signature with date

2013-14/revised

MEDICAL REPORT
(To be certified by a doctor/hospital on the panel of the Indian Mission, UN Mission, if any or as
designated by Indian Mission)
(i) Name of Applicant:

ALFREDO BOLIVAR MURIEL BONILLA

(ii) Age:

42
MALE
175
79.54
B+

(iii) Sex: (Male / Female)

(iv) Height (cm):
(v) Weight (kg):
(vi) Blood Group:
(vii)Blood Pressure:

(Pre-prandial)

( Peak post- prandial)

(viii) Blood Sugar:

1. Is the person examined in good health at

present ?
2. Is the person examined physically and mentally fit
to carry out intensive training away from home?

YES
YES

3. Is the person free of infectious diseases

(tuberculosis, trachoma, skin diseases etc.)?

YES

4. Has the person taken Yellow Fever inoculation (in

case of people coming from Yellow Fever region or as
laid out in WHO Regulations) ? Yellow Fever
Certificate is mandatory.
5. Does the person examined have any chronic
ailment which may require regular treatment/
medication during the course?
6. List of any observed abnormalities indicated in the
chest X ray.

YES

YES
YES

I certify that the applicant is medically fit to undertake a training course in India.
Name of Doctor/Physician:______________________________________________________
Registration No.:______________________________________________________________
Area de salud numero 6
Address of Clinic / Hospital:______________________________________________________
Riobamba
City / Town : _________________________________________________________________
Telephone :_________________________________________________________________
E mail: ___________________________________________
August 28th, 2015
Date: ___________________________________
Signature of Doctor/Physician: ___________________Seal of Clinic/Hospital: _______________

2013-14/revised

UNDERTAKING BY THE APPLICANT

ALFREDO BOLIVAR MURIEL BONILLA

I, _____________________________________________________________________
(Name, Middle name, Family name)
ECUADOR

of (country)_________________________________________ certify that information provided by me in

this form is true, complete and correct.

I also certify that :(i) I have read the course brochure and that I am aware of the course contents and living conditions in India.*
(ii) I have sufficient knowledge of English to participate in the training programme.
(iii) I am medically fit to participate in the Course and have submitted a medical certificate from the designated
doctor.
(iv) I have not attended any programme previously sponsored by Government of India.
(v) I have not applied for or am not required to attend
course/conference/meeting etc. during the period of the course applied for.

any

other

training

If accepted for the ITEC / SCAAP training programme, I undertake to:

(a) Comply with the instructions and abide by Rules, Regulations and guidelines as may be stipulated
by both the nominating and sponsoring Governments in respect of the training;
(b) Follow the full and complete course of study/ training and abide by the Rules of the
University/Institution/ Establishment in which I undertake to study or undergo training;
(c) Submit periodic assessments / tests conducted by the Institute (progress report which may be
prescribed);
(d) Refrain from engaging in political activity, or any form of employment for profit or gain;
(e) Return to my home country at the end of the course of study or training;
(f) I also fully undertake that if I am granted a training award, it may be subsequently withdrawn if I fail
to make adequate progress or for other sufficient cause determined by the host Government.
(g)

I confirm that I will not travel to India to attend the Course applied for in case I am pregnant - (for
lady participants).

Date: August 24th , 2015

Place: Riobamba Ecuador, South America

(SIGNATURE OF THE APPLICANT)

Name: __Alfredo Bolivar Muriel Bonilla

* Details of the course are on the website of the Institute or can be obtained from them through e-mail.

2013-14/revised

PART II
To be completed by the authorized official of the Nominating Government/ Employer
I, __Edith Ordoez Recalde______________________________________________ on
behalf of the Government of____Ecuador_______________________________ certify that:
(a)
I have examined the educational, professional and other certificates quoted by the
nominee in Part I of this form and I am satisfied that they are authentic and relate to the
nominee.
(b)
I have gone through the medical certificates and X-ray reports produced by the nominee
which state that he/she is medically fit and free from any infectious disease and Yellow Fever
and that having regard to his/her physical and mental history there is no reason to indicate that
the nominee is other than fit to undertake the journey to India and to undergo training in India.
(c)
The nominee has adequate knowledge of spoken and written English to enable him/her
to follow the course of training for which he/she is being nominated.
(d)

The nominee has not availed of ITEC/SCAAP training facilities earlier in India.

I nominate Mr./Mrs./Miss____ALFREDO BOLIVAR MURIL BONILLA on behalf of the

Government of____ECUADOR___________________ as employer.

Name of Nominating Authority:__EDITH ORDOEZ RECALDE_____________

Designation:____PRINCIPAL UNIDAD EDUCATIVA PEDRO VICENTE MALDONADO
Address: PRIMERA CONSTITUYENTE Y ESPAA _

Signature
(With seal)
Dr. EDITH ORDOEZ RECALDE
RECTORA DE UNIDAD EDUCATIVA PEDRO VICENTE MALDONADO

Name and Designation

(in block letters)
Date : AUGUST 24TH 2015
Place : Riobamba

2013-14/revised

IMPORTANT NOTICE

Please read the form carefully.

applying.

The application will be automatically rejected if any column is inaccurate,

incomplete or blank.
While filling the form, no abbreviations should be used. Write full name of
degree, organization/institution, designation, etc.

Tick the scheme under which you are

Undertaking by the candidate and the recommendations from employer are

compulsory pre- requisites.

Working knowledge of the English language is a pre-requisite. For English

language and language-related courses, basic knowledge of English is
required.

Candidates are expected to be physically fit to undertake the training

programme in India. It may kindly be noted that medical cover provided by
Government of India is only for any medical emergency arising during the
training programme. For regular medical problems, the candidates are
required to pay for doctors fee and medicines out of their living allowance.

In case a candidate is under medication for some chronic ailment(s) like

hypertension/diabetes, etc., and with the prescribed medication can
undertake the training, the candidate must bring the prescribed medicines
along with him/her for the whole duration of the course.

Female candidates, if pregnant, are advised not to travel to India to attend

the course applied for.

Candidates must abide by the rules and regulations of the Institute.

Candidates who leave the course midway for personal reasons without
prior permission of the Ministry of External Affairs or remain absent from
the programme without sufficient reasons are required to refund the cost of
training and airfare to Government of India.

Candidates interested to visit different parts of India for tourism purposes

will require prior permission of the Ministry of External Affairs.

2013-14/revised