Last Update:  July 19, 2005 

АССАМБЛЕЯ ПО ОЗДОРОВЛЕНИЮ НАСЕЛЕНИЯ

4-8 декабря 2000 года
Savar Gonoshasthaya Kendra, Бангладеш

To download the form, please click here:

• Application Form (Word 97)

Please return form before 20 June 2000 to:

PHM Secretariat secretariat@phmovement.org 

1. CONTACT INFORMATION
(Please note that all fields in this section marked * are REQUIRED)

*Name:
*Position:
*Organisation:
*Postal Address:
*Country:
*Tel No:
Fax No:
*Email:
Website:

*Describe the work of your organisation:



2. WORKSHOP(S)

If you would like to organise workshop(s) during the Assembly (4 - 8 December 2000), please fill this in.

i. Theme of workshop:


   Objectives of workshop:



ii. Theme of workshop:


   Objectives of workshop:



iii. Theme of workshop:


   Objectives of workshop:



3. FORUM

If you would like to organise capacity building workshop(s) during the Forum (10 - 13 December 2000), please fill this in.

Name of organisation(s):


Theme of workshop:


Objectives of workshop:


Expected number of participants:


4. FUNDING

Do you need financial assistance?
No
Yes in full
Yes in part. What is the amount your are able to raise on your own? USD

How much is the cheapest economy excursion fare from your country to Dhaka, Bangladesh?
USD

Can you or your organisation offer financial assistance to other participants?
Yes. How much? USD
No


5. PRE-ASSEMBLY ACTIVITIES

Are you/your organisation involved in any of the pre-assembly activities?
Contributing to the analytical work and formulating of the People's Charter for Health;
        How?


Collecting stories and case studies
        Title of stories/case-studies:
        1.
        2.
        3.
        4.
        5.

Organising local/national/regional meetings
        Theme of meeting/seminar/workshop:


        Venue and dates:

      

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