Online course on ophthalmic instruments maintenance: Part 1 Application form
* denotes mandatory fields
Please ensure the applicant fills-in the nomination form
Personal details:
Prefix *
Name *
Gender *
Date of Birth *
Dr.
Mr.
Ms.
Biruk Tekle Haile
Male
Female
08-Jun-1990
dd-MMM-yyyy
Mobile Number *
Email ID *
Please mention your academic
qualification *
+251
913131303
biruk1313@gmail.com
BSC, MPH candidate
Other
Online course on ophthalmic instruments maintenance: Part 1 Application form
* denotes mandatory fields
Communication Address *
Kolfe keranyo sub city
Street Address
Address Line 2
Addis Ababa
Addis Ababa
City
State/Region/Province
0000
Ethiopia
Country
Postal / Zip Code
Please upload your recent
passport size photo
Biruk_TH.jpg
English Language proficiency *
List other languages known *
Have you attended any other
course at Aravind Eye Care
System / LAICO (please list)? *
Read
Write
Speak
Amharic
Yes
No
Online course on ophthalmic instruments maintenance: Part 1 Application form
* denotes mandatory fields
Please mention the course detail
Customized training on refraction.
Hospital management and system development.
Organisational details:
Organisation Name *
Organisation Type *
Designation *
Organisation Address *
MCM General Hospital
Others
General Hospital
Wereda 14, Gerji, Addis Ababa, Ethiopia
Street Address
Address Line 2
Addis Ababa
City
0000
Postal / Zip Code
Phone Number *
Name of the Reporting authority *
+251 116 295 421
Dr John Kempen
Addis Ababa
State/Region/Province
Ethiopia
Country
Online course on ophthalmic instruments maintenance: Part 1 Application form
* denotes mandatory fields
Designation of Reporting
authority *
President, Sight for Souls
Mobile Number of Reporting
authority *
Email ID of Reporting authority *
+251
944121904
kempenjh@yahoo.com
Course Fee Payment Details
Self
Payment by *
Sponsoring Organisation Name *
Contact Person *
Email ID of the Contact Person *
Address of the Sponsoring
Organisation *
My Organisation
Other Sponsor
LAICO Partner hospital
HCP
Dr Liknaw Adamu
liknawa@cureblindness.org
Bole sub-city,
Street Address
Addis Ababa, Ethiopia
Address Line 2
Addis Ababa
City
0000
Postal / Zip Code
Addis Ababa
State/Region/Province
Ethiopia
Country
Online course on ophthalmic instruments maintenance: Part 1 Application form
* denotes mandatory fields
Information for Course design:
Briefly describe your current role
and responsibilities *
I am currently working as Chief Optometrist and Admin- coordinator for the
eye unit. I also involve on maintaining and setting up diagnostic instruments.
Current challenges that you face
in your work *
Due to lack of trained personnel especially on ophthalmic instruments, we are
facing challenge to repair and maintain routinely used instruments.
What do you expect to learn from
this course? *
Describe your areas of
specialisation, interest and
capabilities that would, in your
opinion, contribute to classroom
I expect to learn how to maintain, repair and service routinely used
ophthalmic and surgical instruments.
I am experienced on setting up patient friendly working environment.
discussions *
How did you hear about this
course? *
Throuhr HCP
I hereby declare that the information provided in this application and the supporting documentation are
correct and complete. *