THE PAST IS ALWAYS AHEAD OF US: EM POWERING

INDIGENOUS AND MINORITY LEADERS PROJECT

Funded by the Bureau of Educational and Cultural Affairs, U. S. Department of State,
Northern Illinois University in partnership with International Visitors Program-Philippines and
Tuklas Katutubo

A THREE-WEEK U.S. -BASED TRAINING AND STUDY TOUR PROGRAM

APPLICATION FORM

Instructions:
Please print legibly and see to it that all information being asked from you in this Application Form is complete
and truthfully answered. Do not leave any item unanswered. Incomplete entries and supporting documents will not
be accepted. Place your accomplished application form and all documents in an envelope and submit it to your
Local and Regional Coordinators or to the address stated below not later March
than 15, 2010
. Any applicant
without the institutional endorsement will not be considered.

�Male �Female
Name: ______________________________________________________________

Home Address: ___________________________________________________________________________

________________________________________________________________________________________

Tel. #: ____________________________________ Mobile #: ___________________Email:_____________

Age: _________________________Date of Birth: ___________________ Marital Status:_______________

Religion/Ethnic Identity:___________________________________________________________________

Occupation: ___________________________________ Educational Attainment:_____________________

Do you currently hold a Passport? � Philippine � Others, specify _____________

If Married, Name of Spouse: _____________________________ Occupation: _______________________

Number and Ages of Children:_______________________________________________________________

Father’s Name: ________________________________________ Ethnic Identity: ____________________

Mother’s Name: ________________________________________ Ethnic Identity: ____________________

Parents’ Address: ________________________________________________________________________

________________________________________________________________________________________

Name and Address of Employer: ____________________________________________________________

________________________________________________________________________________________

Field of Specialization:_____________________________________________________________________
________________________________________________________________________________________

Membership in organizations for the last three (3) years:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Membership in civic organizations or NGOs for the last three (3) years (list dates)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____

Titles and Dates of Seminars/W orkshops actively participated in for the last three (3) years:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

OTHER REQUIREMENTS
1. Essay:

On a separate sheet of paper write something about your community and your vision for your community.

2. Documents:

a) Photocopy of Birth Certificate(preferably printed in NSO Security Paper

)
b) Certificate of authenticity from the NCIP for applicants representing the indigenous communities and
OMA for applicants representing Bangsamoro OR letter of recommendation/endorsement from the
community elder or chieftain
c) Photocopy of your Certificates of Membership in Organizations (optional)
d) Photocopy of your Certificates of Attendance/Participation in Seminars and Workshops (optional)

I hereby certify that the above information on my application form and the required documents are true to the best
of my knowledge. I also certify that I am not related
within third degree of consanguinity and affinity to any of the
regional coordinators
. As participant I will participate actively in the Program. Any false information may cause
my disqualification.

________________________________________ _______________________
Signature of Applicant Date

PIease send Application to:

Zamboanga, Basilan, Sulu, Tawi tawi Coordinator:

Alber Husin (alber.husin@gmail.com)
124 Middle Nivel Hills, Apas, Cebu City 6000

Lanao, Cagayan de Oro, Iligan and Bukidnon Coordinator:

Anisha Elin Guro (elin.anisha@gmail.com) - 0926 928 0009
007 Mars St., Rabago Subdivision, Villaverde, Iligan City 9200 OR
MSU Press and Information Office, Marawi City 9700

North Cotabato, Cotabato City, Maguindanao, Sultan Kudarat Coordinator:

Tarhata Maglangit - (bwsf05@yahoo.com or bwsf.secretariat@gmail.com)
Bangsamoro Women Solidarity Forum, Inc.
#22-E Sekak Apt., Gonzalo Javier Street, Rosary Heights 7
Cotabato City 9600, Philippines
Telefax No: (064) 421-4439

Saranggani, Caraga, North Cotabato, South Cotabato, Davao

Coordinator:
Jason Sibug pangulimansibug@yahoo.com
( )
77 Gold St., Filinvest II, Quezon City