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<!-- <p class="topheading"><strong>Asia Pacific Network Information Centre</span></strong></p> -->
<h1>Fellowship application</h1>
<p>This form is available till <b>Friday, 31 October 2014</b>.</p>
<form action="submit.php" method="post">
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input[type=text],
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<table class="invisible">
<tr><th colspan="2">Personal information</th></tr>
<tr><td>First Name:<sup>*</sup><br>(as shown in passport)</td><td><input type="text" name="first_name" value=""></td>
</tr>
<tr><td>Last Name:<sup>*</sup><br>(as shown in passport)</td><td><input type="text" name="last_name" value=""></td>
</tr>
<tr><td>Country of residence:<sup>*</sup></td><td>
<select name="passportcountry">
<option value=''>Select</option>
<option name='Afghanistan' value='AF'>Afghanistan</option>
<option name='Bangladesh' value='BD'>Bangladesh</option>
<option name='Bhutan' value='BT'>Bhutan</option>
<option name='India' value='IN'>India</option>
<option name='Maldives' value='MV'>Maldives</option>
<option name='Nepal' value='NP'>Nepal</option>
<option name='Pakistan' value='PK'>Pakistan</option>
<option name='Sri Lanka' value='LK'>Sri Lanka</option>
</select>
</td></tr>
<tr><td>Country of employment:<sup>*</sup></td><td>
<select name="employmentcountry">
<option value=''>Select</option>
<option name='Afghanistan' value='AF'>Afghanistan</option>
<option name='Bangladesh' value='BD'>Bangladesh</option>
<option name='Bhutan' value='BT'>Bhutan</option>
<option name='India' value='IN'>India</option>
<option name='Maldives' value='MV'>Maldives</option>
<option name='Nepal' value='NP'>Nepal</option>
<option name='Pakistan' value='PK'>Pakistan</option>
<option name='Sri Lanka' value='LK'>Sri Lanka</option>
</select>
</td></tr>
<tr><td>Gender:<sup>*</sup></td><td>
<select name="gender">
<option value="">Select</option>
<option name="Male" value="Male">Male</option>
<option name="Female" value="Female">Female</option>
</select>
</td></tr>
<tr><td>Address:</td><td><input type="text" name="address" value=""></td></tr>
<tr><td>Email:<sup>*</sup></td><td><input type="text" name="email" value=""></td></tr>
<tr><td>Telephone:<br>(include international and area codes)</td><td><input type="text" name="telephone" value=""></td></tr>
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<tr>
<td>Website:<sup>*</sup></td>
<td><textarea cols="35" rows="2" name="website"></textarea></td></tr>
<tr><th colspan="2">Work history</th></tr>
<tr><td>Employer:<sup>*</sup></td><td><input type="text" name="employer" value=""></td></tr>
<tr><td>Type of organisation<br>(ISP/IXP/educational network /telco/etc)<sup>*</sup></td><td><input type="text" name="organizationtype" value=""></td></tr>
<tr><td>Position Title:<sup>*</sup></td><td><input type="text" name="position" value=""></td></tr>
<tr><td>Current responsibilities and areas of interest:<sup>*</sup></td><td><textarea name="responsibility" value="" rows="10
" cols="30"></textarea><p style="margin-top:0px;">Please write no more than 100 words.</p></td></tr>
<tr><td>How will this fellowship benefit your organisation or country?<sup>*</sup></td><td><textarea name="benefit" value=""
rows="10" cols="30"></textarea><p style="margin-top:0px;">Please write no more than 100 words.</p></td></tr>
<tr><td colspan="2">Provide two referees from your organisation that we can contact to verify/support your application?</td></tr>
<tr><td>Name of first referee:<sup>*</sup></td><td><input type="text" name="referee1name" value=""></td></tr>
<tr><td>Email of first referee:<sup>*</sup></td><td><input type="text" name="referee1email" value=""></td></tr>
<tr><td>Name of second referee:</td><td><input type="text" name="referee2name" value=""></td></tr>
<tr><td>Email of second referee:</td><td><input type="text" name="referee2email" value=""></td></tr>
<tr><th colspan="2">Other supporting information</th></tr>
<tr><td>How many SANOG meetings have you attended?<sup>*</sup></td><td><select name="howmanymeetings"><option name="0" value="0">0</option>
<option name="1" value="1">1</option>
<option name="2" value="2">2</option>
<option name="3" value="3">3</option>
<option name="4" value="4">4</option>
<option name="5" value="5">5</option>
<option name="6" value="6">6</option>
<option name="7" value="7">7</option>
<option name="8" value="8">8</option>
<option name="9" value="9">9</option>
<option name="10" value="10">10</option>
<option name="11" value="11">11</option>
<option name="12" value="12">12</option>
<option name="13" value="13">13</option>
<option name="14" value="14">14</option>
<option name="15" value="15">15</option>
<option name="16" value="16">16</option>
<option name="17" value="17">17</option>
<option name="18" value="18">18</option>
<option name="19" value="19">19</option>
<option name="20" value="20">20</option>
<option name="21" value="21">21</option>
<option name="22" value="22">22</option>
<option name="23" value="23">23</option>
<option name="24" value="24">24</option>
</select></td></tr>
<tr><td>What are the 3 sessions of highest priority you would like to attend?<sup>*</sup> </td><td><textarea name="whichtrainings" value="" rows="10" cols="30"></textarea><p style="margin-top:0px;">Please write no more than 100 words.</p></td></tr>
<tr><td>Have you ever received any fellowships to SANOG, APRICOT or an APNIC meeting ?</td><td><input type="radio" name="otherfellowship" value="yes">Yes <input type="radio" checked name="otherfellowship" value="no" >No</td></tr>
<tr><td>Tentative itinerary:<sup>*</sup></td><td><input type="text" name="itenerary" value=""><p style="margin-top:0px;">Eg: Dhaka-Kathmandu-Dhaka</p></td></tr>
<tr><td>Flight cost:<sup>*</sup></td><td><div style="position:relative;left:-23px;">US$<input type="text" name="flightcost" value=""></div></td></tr>
<tr><th colspan="2">Accommodation and Travel</th></tr>
<tr><td>I agree to shared accommodation?<sup>*</sup></td><td><input type="radio" name="shareaccom" value="yes" checked>Yes <input type="radio" name="shareaccom" value="no" >No</td></tr>
<tr><td>I am liable for my own visa, travel and insurance costs.?<sup>*</sup></td><td><input type="radio" name="liable" value="yes" checked>Yes <input type="radio" name="liable" value="no" >No</td></tr>
<tr><td> </td><td> </td></tr>
<tr><td> </td><td> </td></tr>
<tr><td><input type="submit" value="Submit"></td><td><input type="reset" value="Clear fields"></td></tr>
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Acknowledgements: <a href="http://www.apnic.net/" target="_blank" >APNIC,</a> <a href="http://www.apricot.net/" target="_blank" >APRICOT,</a> <a href="http://www.sanog.org/" target="_blank" >SANOG</a>
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