HOMELAND SECURITY REGISTRATION FORM FOR COURSE/SEMINAR

Transcription

1 HOMELAND SECURITY REGISTRATION FORM FOR COURSE/SEMINAR The following form must be filled out and signed in order to register for a course/seminar. It must be forwarded at least 30 days prior to the start of the course/seminar. Course/Seminar Date of Course/Seminar: (DD/MM/YY)! After filling out the form, please sign the confirmation clause (on the last page) and send by registered mail, along with the documents listed below, to: BESA Center, Bar Ilan University, Ramat Gan Israel REQUIRED DOCUMENTS The following documents must be submitted with the registration form: 1. Medical certificate from certified doctor that you are physically in good health and fit to engage in physical and stressful activity 2. Official document of no criminal record 3. Photocopy of passport & one passport-size photo 4. Photocopy of official weapon permit 5. Completed and signed registration form 6. Registration fee of $200 (see details below) 1. PERSONAL DETAILS Surname: Name of Father: Name of Mother: ID No.: Passport No.: Sex: Date of Birth: Place of Birth: Country of Origin: Nationalities: Citizenships:

2 2 2. ADDRESS Street: City: State / Country: Home Telephone No.: Cellular No.: Valid address: Work Telephone No: Address of Employment: 3. EDUCATIONAL BACKGROUND Institute Name Years of Study Dates Diploma High School College University 4. KNOWLEDGE OF LANGUAGES Language Reading Writing Speech 5. CRIMINAL RECORD Yes No Explain:

3 3 6. SERVICES IN THE ARMY / POLICE / SECURITY FORCES Unit Division Name Enlistment Date Discharge Date ID Number Title 7. PROFESSIONAL COURSES / SEMINARS DURING SERVICE Date Name of Course/Seminar Duration Diploma 8. DO YOU HAVE A PERMIT TO CARRY A WEAPON? Yes No Type of weapon: Caliber: 9. COURSES IN COMBAT SHOOTING Date Name of Course Duration Diploma

4 4 10. EXPERIENCE IN MARTIAL ARTS Yes No 11. SPECIAL COURSES / SEMINARS OUTSIDE YOUR COUNTRY Name of Course/Seminar Country Duration Diploma 12. EMPLOYMENT HISTORY Employer Address Duration Comments 13. RECOMMENDATIONS Name Title Address Telephone

5 5 14. TRIPS ABROAD DURING THE LAST 5 YEARS Country Date Reasons Duration of stay Contact person in country 15. VISITS TO ANY MUSLEM COUNTRIES Yes No If yes, please specify: 16. MEDICAL DETAILS & DECLARATION OF GOOD HEALTH A. MEDICAL DETAILS Blood type: Height: Cm. Weight: Kg. B. IN CASE OF ACCIDENT PLEASE NOTIFY: Phone No.: Phone No.: Phone No.: C. MEDICAL INSURANCE Yes No If yes, please write which type of insurance :

6 6 D. ALLERGIES Yes No Explain: E. HEALTH PROBLEMS & PHYSICAL LIMITATIONS (DESCRIBE) F. DECLARATION OF GOOD HEALTH I declare that I am physically and mentally in good health and capable of participating in a course/seminar given by Condor. I declare that I have no disabilities, injuries or illnesses that may impede my participation in the course/seminar. With this declaration, I absolve BESA and Condor of any responsibility for any damages, including bodily & pecuniary injuries that might happen to me during the course/ seminar and/or as a result of participating in it. I therefore declare that I am responsible for any expenses including medical expenses during and/or after the course/seminar. 17. ARTICLES & REGULATIONS OF A COURSE / SEMINAR A. OBLIGATIONS The rules are designed to explain the conditions required to follow in order to participate in a course/seminar. B. FEES 1. The registration to a course/seminar is definite only after BESA-Condor has received all requirements from the participant as stated in the registration form. 2. The participant or his employer must pay the complete fee at least 30 days prior to the beginning of the course/seminar. 3. BESA-Condor reserves the right to refuse the participation of a student without having to state and explain its reasons. 4. In case of cancellation up to 14 days prior to the beginning of the course/seminar, 50% of the payment will be refunded. In case of cancellation less than 14 days prior to the beginning of the course/seminar, or absence of the

7 7 participant, the payment will not be refunded and will serve to cover all expenses and losses incurred by BESA-Condor. 5. In case of cancellation by BESA-Condor, the full payment will be refunded. Price of Course/Seminar: US$! There is a non-refundable registration fee of $200. Please include this with your registration form. This will be deducted from the total course fee if the applicant is accepted into the program. Payment options You must pay both the registration fee and the final course fee (if accepted to the program) by making a net bank transfer to: Account name: Bar Ilan University Account number: Name of bank: Mizrahi Tefahot Swift code: MIZBILIT IBAN: IL C. DISCIPLINE Participants must display good behavior in accordance with the ethical requirements of BESA-Condor. Schedules must be respected and class attendance is mandatory. A participant who fails to respect these rules will receive a warning. If this behavior repeats itself, BESA-Condor reserves the right to dismiss a participant from a course/seminar with no refund 18. GOVERNING LAW Any dispute in any way related to the course/seminar is governed by the laws of Israel and by Israeli court.

8 8 CONFIRMATION I State and confirm that all the details written in this registration form are true and correct. I state and confirm that I will accept all of BESA-Condor s rules & regulations as written in this form and commit myself to respecting them. I state and confirm that I will sign a declaration of secrecy and confidentiality upon initiation of the course/seminar. Surname: Passport No.: Date: Signature: