ANEXO I

FICHA DE ENSCRIPCIN DEL POSTULANTE

Remitir al Punto Focal correspondiente en la fecha establecida por ste

debidamente llenado y firmado en original en papel. Adjuntar adems
todos los documentos escaneados en un CD rotulado con nombre del
candidato, nombre del curso y ao de realizacin.
NOTA: no se considerarn postulaciones incompletas, ilegibles o fuera
de plazo, ni sin oficializacin del Punto Focal.
1. ANTECEDENTES PERSONALES
Nombre completo: _______________________________________________________________
Nacionalidad: __________________________________________________________________
Pas: __________________________________________________________________________
Fecha de nacimiento: Da:__________Mes: :_______________ Ao: :______________________
Lugar de nacimiento: _____________________________________________________________
Sexo (indicar con una cruz): M_____ F__________
Estado civil: ____________________________________________________________________
Nombre del cnyuge: _____________________________________________________________
Direccin Privada
Direccin: _______________________________________________________________________
________________________________________________________________________________
Comuna/Provincia:_____________________________ Apartado Postal:____________________
M de telfono:_________________________________Fax:_______________________________
Email 1:_________________________________________________________________________
Email 2: _________________________________________________________________________
N Pasaporte:_____________________________________________________________________
Lugar de emisin:_________________________________________________________________
Fecha emisin: ____________________ _Fecha vencimiento:______________________________
No de Cdula de Identidad: _________________________________________________________
Lugar de emisin:_________________________________________________________________
Fecha emisin:____________________Fecha vencimiento:________________________________

Persona a notificar en caso de emergencia

Nombre:_________________________________________________________________________
Parentesco:______________________________________________________________________
Direccin completa ________________________________________________________________
________________________________________________________________________________
Ciudad / Pas : ___________________________________________________________________
Telfono / Fax / E-mai1 :____________________________________________________________
2. ANTECEDENTES PROFESIONALES
Nombre institucin: ____________________________________________________________
______________________________________________________________________________
Direccin :_______________________________________________________________________
_______________________________________________________________________________
Ciudad _______________________________________Pas : ____________________________
Telfono : __________________________________Fax : _____________________________
E-mail : _________________________________
Cdigo postal : ___________________________
Cargo actual :____________________________________________________________________
_______________________________________________________________________________
Tiempo en el cargo: ______________________________
Nmero de profesionales a cargo:____________________________________________________

Principales Actividades de la Institucin

Nmero de funcionarios:_ _______________________________________
Actividad del candidato:
(

) Investigacin

) Enseanza

( ) Administracin -

Polticas
(

) Produccin

( ) Extensin

) Fomento y

Otros
(especificar):___________________________________________________________________
Nombre y cargo de superior jerrquico de institucin a ser contactado durante y despus del curso:

Nombre: _______________________________________________________________________
Cargo:__________________________________________________________________________
Direccin:_______________________________________________________________________
________________________________________________________________________________
Ciudad:__________________________________________________________________________
Telfono:_____________________________ Fax :______________________________________
3.

CURRICULUM VITAE DEL POSTULANTE

Grado acadmico:________________________________________________________________
Ttulo profesional:________________________________________________________________
Ao de egreso:___________________________________________________________________
Nombre Universidad:______________________________________________________________
________________________________________________________________________________
Ciudad :_________________________________________________________________________
Especialidad principal:_____________________________________________________________
Otros (seale):

Experiencia profesional (ltimos aos). Indicar fechas (aos), institucin empleadora y

principales funciones. Anexar hoja aparte si fuera necesario.
1.
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2.
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3.
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4.
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5.
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Curso de Post-grado o perfeccionamiento. Indicar pas, universidad, nombre del curso y fecha
de realizacin.
1.
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2.
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3.

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4.
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5.
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Viajes de Estudio
1.
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2.
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3.
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4.
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5.
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Otros cursos relevantes (Manejo Integrado Zona Costera, Manejo Pesqueras, Recursos
Hidrobiolgicos, Ecologa de Recursos Marinos, etc.)
1.
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2.
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3.
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4.
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5.
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Explique las razones que fundamentan su postulacin
1.
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2.
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3.
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4.
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5.
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Describa las posibilidades de aplicacin de metodologas de acuicultura y produccin masiva de

recursos hidrobiolgicos en su institucin.
1.
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2.

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3.
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4.
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