This document contains an application form for a Certificate Program in Community Development and Civic Empowerment taking place from September 22 to December 21, 2014 at Chiang Mai University in Thailand. The application requests basic personal information, education and work history, language skills, community development experience, and two recommendation letters to be submitted by July 10, 2014.

1. APPLICATION FORM FOR THE
CERTIFICATE PROGRAM IN COMMUNITY DEVELOPMENT AND
CIVIC EMPOWERMENT (CDCE)
Faculty of Social Sciences
Chiang Mai University, Chiang Mai, Thailand
Program Dates: September 22 – December 21, 2014
Application Deadline: July 10, 2014
Please submit your completed application, essays, passport or NRC copy, photo, and two
recommendations by July 10, 2014 to cdceprogram@gmail.com.
Name (spelled as it appears on your Passport or NRC): ………....
……………………………….…………………
Nickname(s):
………………………………………………………………………………
Date of Birth: …....…………………………..…… Age: ……..…..…
Sex: M / F ……………..
Nationality: …………….……… Ethnicity:
…………………………...…… Religion: ……..………………
Marital Status: Single Married Divorced Widowed
Personal Contact Information:
Address: ……………………………………………………………………………………………...……
……………………………………………………………………………………………………
Telephone: ……………………………… Is this phone number care of (c/o)? Yes No
Email: ........…………………………………………………………………………………………...……
Do you currently have a VALID passport? (This is not a qualification)
Yes No In the process of applying In the process of extending
• If yes or if extending, please write your passport number here: ………………………….……………..
Please also send a copy of your passport photo page with this application (and extension page, if
applicable)
• If you do not have a passport, attach a copy of your NRC notary with this application.
1
Application #: Shortlist #:
For CDCE office use: (Do not write in)
Please paste a passport-
size photo of yourself
here (2 inches by 2
inches) and scan with
high resolution.

2. Languages: Please rate your language skills on a scale of B=Beginner, I=Intermediate, A=Advanced, F=Fluent
Language Reading Writing Speaking Listening
English
Burmese
Other:
Other:
Work Experience/History
Where are you currently working? (Name of Organization)
………………………………………………………………………………………………………….……………..
Work Address:
………………………………………………………………………………………………...…………………..…..
………………………………………………………………………………………………………………..……….
.
Organization Email: ……………………………………. Organization Website: ……………………………..
Job Title (Position): ……………………………………………...………….......……………………...
Responsibilities/Duties: …………………………………………………..……...................……….
……….............……….............……….............……….............………...................………………..
How long have you worked here? …….…………………...……………………….………………
How many hours per week do you spend working at this position? ……………………..………..
Organizational Profile: (Please tell us about the background, mission and activities of your organization.
(maximum 100 words.)
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
What other jobs do you have now or did you have in the past?
Job title: ……………………………………… Organization: ………………………………….
Location: ……………………………………… Dates: ………………………............……………
Responsibilities/Duties: …………....……………………………………………………………….
2

3. ……………………………………………………………………………………………………......
Job title: ……………………………………… Organization: ………………………………….
Location: ……………………………………… Dates: ………………………............…………...
Responsibilities/Duties: …………....………………………………………………………………
……………………………………………………………………………………………………...
Education
Highest Education Level Attained: ……………………………………………………………..
What schools have you attended?
Name: ……………………………………… Location:……………… Dates: ……………....
Name: ……………………………………… Location:……………… Dates: ……………....
What trainings or workshops have you attended?
1. Name of Training:………………………………………....…………………………………
Organized by: ……………....………….... Location:………………………Dates: ……………....
2. Name of Training:………………………………………....……………………….…………
Organized by: ……………....………….... Location:………………………Dates: ……………....
3. Name of Training:………………………………………....……………………… ……………
Organized by: ……………....………….... Location:………………………Dates: ……………....
4. Name of Training:………………………………………....……………………………………
Organized by: ……………....………….... Location:………………………Dates: ……………....
3

4. Specific Skills and Interests
From the list below, which are the TOP 3 issues and approaches that interest you most?
□ Poverty Reduction □ Project Design □ Education □ Peacebuilding
□ Interfaith □ Advocacy □ Environment □ Economic Development
□ Microcredit □ Training □ HIV/AIDS □ Local Governance
□ Media □ Gender □ Research □ Other __________________
□ Health □ Agriculture □ Disabilities
□ MSM □ Migration □ Youth
Have you ever been involved in a training program as a curriculum designer, trainer, support staff or
evaluator?
Yes No
If yes, please describe your experience in the table below.
Name of Training
How long was the
training? How many
times have you
implemented it?
Location Responsibilities
Curriculum Designer Trainer
Support Staff Evaluator
Other: .…………………………….
Curriculum Designer Trainer
Support Staff Evaluator
Other: .…………………………….
Curriculum Designer Trainer
Support Staff Evaluator
Other: .…………………………….
Curriculum Designer Trainer
Support Staff Evaluator
Other: .…………………………….
Do you have an experience with advocacy? Yes No
If yes, please briefly explain below:
4

5. Have you ever been involved in any research projects, assessments, monitoring or evaluation
processes as a research designer, numerator, data analyst or report writer?
Yes No
If yes, please describe your experience in the table below.
Research Topic
Who initiated and
implemented this
research
Location Responsibilities
Research Designer Numerator
Data Analysts Report Writer
Other: .…………………………….
Research Designer Numerator
Data Analysts Report Writer
Other: .…………………………….
Research Designer Numerator
Data Analysts Report Writer
Other: .…………………………….
Research Designer Numerator
Data Analysts Report Writer
Other: .…………………………….
Recommendations
Names of and information about the people writing your recommendation letters:
1. Name: ……………………………………………………………………………………………
Organization: …………………………… Position: ……………………………………..……….
Address: ……………………………………………………………………………………………
Email ……………………………………………… Telephone: …………………………………
2. Name: ……………………………………………………………………………………………
Organization: …………………………… Position: ……………………………………..……….
Address: ……………………………………………………………………………………………
Email ……………………………………………… Telephone: …………………………………
If possible, please have your recommenders send the separate recommendation form directly to
cdceprogram@gmail.com
5

6. Applicant Essay Questions
Answer the following essay questions to the best of your ability. Please follow the word limits carefully.
1. Please describe your previous experience in community development activities? (Maximum 500
words)
2. Why are you interested in this program? After finishing the CDCE program, what do you hope to be
able to do? What improvements do you want to make in your organization and community? Detailed
answered are appreciated. (Maximum 500 words)
3. In your opinion, how is your personal work connected to or helping with the democratic transition
that is taking place in Myanmar at this time? (Maximum 500 words)
4. Imagine one of the communities that you know well. What important message would you like to
share with them to improve their lives? How would you plan to share it? (Maximum 300 words)
5. Please give an example of a time when you faced a difficulty in your work. What was the situation?
How did you solve or deal with that difficulty? (Maximum 300 words).
I certify that I wrote these essays and application form by myself.
Signed _____________________________________________ Date ___________
Please send your completed application to: cdceprogram@gmail.com
Application Deadline is July 10, 2014
6

7. CDCE Training Program: September 22 – December 21, 2014
(APPLICATION DEADLINE is July 10, 2014)
RECOMMENDATION FOR ………………………………………………………
(Name of Applicant)
SECTION 1:
Your name: ………………………...…………………………………………………..………
Name of organization: ……………………………………………………………………....…
Responsibility within the organization: ...………………………………………………….......
SECTION 2:
Please answer the following questions:
How long have you known the applicant? ………………………………………………..
Please explain your relationship to the applicant: ……………………..…………………………………..
………………………………………………………………………………………………………………
Please comment on what features/characteristics of the applicant will enable him/her to successfully
study at an intensive course, in Thailand, focused on community development.
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………
Please comment on the applicant’s ability to use his or her knowledge about community development
and civic empowerment in the future. NOTE: If you are the supervisor of this applicant, please explain
in detail the plans that your organization has for this individual upon his/her return to your organization.
………………………………………………………………………………………….…..………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
7

8. ……………………………………………………………………………………………………………
………
8

9. SECTION 3:
Please give an assessment of the applicant’s skills and abilities in the following areas. Rate the applicant
on a scale of 1 to 5. Note: 1 = Poor; 2 = Fair; 3 = Good; 4 = Very Good; 5 = Excellent; ? = Not sure
Applicant’s ability to live independently and take care of him/herself (.………)
Applicant’s ability to undertake serious and intensive study (……….)
Applicant’s tolerance of diversity in terms of race, religion, gender, etc. (……….)
Ability of applicant to foster friendly and respectful relations with others (……….)
Ability of applicant to apply knowledge and skills to real-life situations (……….)
Ability of applicant to communicate openly and reasonably (……….)
Ability of the applicant to working in team settings (……….)
Applicant’s commitment to doing community development work (……….)
Applicant’s level of experience working at the grassroots level (……….)
Applicant’s ability to communicate in the English language (……….)
Applicant’s ability to advocate or share information with a broad audience (……….)
Applicant’s potential for doing research (……….)
Applicant’s potential to be a trainer (……….)
Please use the following space to make any other relevant comments about the applicant:
…………………………………………………………………………………………….
…………………………………………………………………………………………….
I, __________________________________, certify that ________________________________________
(Your Name) (Name of Applicant)
is a: (chose one) ideal strong satisfactory not fully qualified
candidate for admission into the CDCE Program.
Signed: ………………………………………………… Date: …………………………
Please return the completed recommendation form directly to cdceprogram@gmail.com
9

10. CDCE Training Program: September 22 – December 21, 2014
(APPLICATION DEADLINE is July 10, 2014)
RECOMMENDATION FOR ………………………………………………………
(Name of Applicant)
SECTION 1:
Your name: ………………………...…………………………………………………..………
Name of organization: ……………………………………………………………………....…
Responsibility within the organization: ...………………………………………………….......
SECTION 2:
Please answer the following questions:
How long have you known the applicant? ………………………………………………..
Please explain your relationship to the applicant: ……………………..…………………………………..
………………………………………………………………………………………………………………
Please comment on what features/characteristics of the applicant will enable him/her to successfully
study at an intensive course, in Thailand, focused on community development.
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………
Please comment on the applicant’s ability to use his or her knowledge about community development
and civic empowerment in the future. NOTE: If you are the supervisor of this applicant, please explain
in detail the plans that your organization has for this individual upon his/her return to your organization.
………………………………………………………………………………………….…..………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………
10

11. SECTION 3:
Please give an assessment of the applicant’s skills and abilities in the following areas. Rate the applicant
on a scale of 1 to 5. Note: 1 = Poor; 2 = Fair; 3 = Good; 4 = Very Good; 5 = Excellent; ? = Not sure
Applicant’s ability to live independently and take care of him/herself (.………)
Applicant’s ability to undertake serious and intensive study (……….)
Applicant’s tolerance of diversity in terms of race, religion, gender, etc. (……….)
Ability of applicant to foster friendly and respectful relations with others (……….)
Ability of applicant to apply knowledge and skills to real-life situations (……….)
Ability of applicant to communicate openly and reasonably (……….)
Ability of the applicant to working in team settings (……….)
Applicant’s commitment to doing community development work (……….)
Applicant’s level of experience working at the grassroots level (……….)
Applicant’s ability to communicate in the English language (……….)
Applicant’s ability to advocate or share information with a broad audience (……….)
Applicant’s potential for doing research (……….)
Applicant’s potential to be a trainer (……….)
Please use the following space to make any other relevant comments about the applicant:
…………………………………………………………………………………………….
…………………………………………………………………………………………….
…………………………………………………………………………………………….
I, __________________________________, certify that ________________________________________
(Your Name) (Name of Applicant)
is a: (chose one) ideal strong satisfactory not fully qualified
candidate for admission into the CDCE Program.
Signed: ………………………………………………… Date: …………………………
11

12. Please return the completed recommendation form directly to cdceprogram@gmail.com.
12