______________________________________________ Fellowship application form - SANOG IV ______________________________________________ Please clearly fill this form and submit by email to by 1 June, 2004. ---------------------- Personal information ---------------------- Full name (as shown in passport, with surname first): Passport number and Country : Gender: Full postal address: Resident of: Email: Telephone (include international and area codes): Fax (include international and area codes): ---------------------- Work history ---------------------- Employer: Type of organisation (ISP/IXP/educational network /telco/etc): Position: Current responsibilities and areas of Interest: How will this fellowship benefit your organisation or country? Provide two referees from your organisation that we can contact to verify/support your application? ---------------------- Other supporting information ---------------------- How many SANOG meetings have you attended? Which training and meeting sessions are you interested to attend? Have you ever received any fellowships to SANOG, APRICOT or an APNIC meeting ? ---------------------- Travel arrangements ---------------------- What would be your most direct route to Kathmandu from your country/city? Please indicate overland routes, if any. Please provide a tentative itinerary with estimated travel cost. ---------------------- Fellowship Obligation ---------------------- Will you be able to pay the USD175 or equivalent towards your participation at SANOG IV? --------------------------------------------------------------------- Please send the application back to info@sanog.org by 1 June, 2004.