REGISTRATION FORM

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Name………………………………………………………………………………………….

Name (s) .............. ................................................................................................

Date and place of birth…………………………………………………………………….................…… ............................................................................................. ...........

Profession…………………………………………………………………………………

Address……………………………………………………………………………………

             Such.………………………....................................... .......................................... Fax ..................... .................................................. ................................ .................. .................................................. ........................................ E-mail……………………… ... ................................................. .....................
Country .......................................... / City ................................................... I would like to register for the internship of ..................... .................................... ...................................... ............

 For a period of …………………………………. MONTH

From the month of: (month and year) ......................................................... .................... ..............................

Have you ever participated in an internship in Togo? ................................. ................................................... .......................

If yes which ? .......................................................................................... .................

Why would you like to participate in a CID-TOGO internship? ............ .............................................. .................................................

............................................................................................................
                   Done at .............................. .., on ...........................................


                   Signature:

 
Center for Interaction for Development - TOGO (CID-TOGO) 14BP: 243 lome- Togo;
Tel (00228) 2230 05 47; (00228) 98209090;
(00228) 995794 68, (00228 )92749273
Cid_togo@yahoo.fr or kinongo90@yahoo.fr