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2021 MIKTA Young Leaders CampBasic InformationNameEnglish(Last Name) (First Name) ______ ___<Photo>Native Language(Last Name) (First Name) ______ ___Gender FORMCHECKBOX Female FORMCHECKBOX MaleDate of Birth______(Y) ____(M) ____(D)NationalityCountry of Current ResidencyCurrent PositionInstitutionDepartmentPositionAddressPostal CodeTelephone NumberE-mail AddressT-shirt Size (S/M/L/XL/ XXL)Allergy and Dietary restrictionsAllergy :Dietary restrictions : (ex : Pork, Beef..)2.Education & Career2.1Education (*List most recent first)Period: From-ToInstitutionMajor (Field)Degree2.2Work Experience (*List most recent first)Period: From-ToInstitution/Company NamePosition Title(X) Degree2.3Dissertations & Publications3.Language Ability3.1Native Language(s): ____________3.2Non-native Language(s)Language(s)ProficiencyEnglish□ None□ Basic□ Intermediate□ Competent□ Fluent □Native□ None□ Basic□ Intermediate□ Competent□ Fluent □Native□ None□ Basic□ Intermediate□ Competent□ Fluent □Native4.Special Qualifications5.Dietary restrictionsPlease include dietary restrictions due to allergy, personal preference, or religious reasons.6. Additional CommentsPlease include any additional comments you may have including any health or religious practices that may prevent you from participating in all activities during the Camp. We will do our best to accommodate all participants.7.Statement of PurposePlease provide a description of personal qualifications and a statement indicating why you would like to participate in the program. Also include any future plans, including research, social campaigns, etc. ................
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