GOVERNMENT OF INDIA

MINISTRY OF EXTERNAL AFFAIRS

INDIAN TECHNICAL AND ECONOMIC COOPERATION ( ITEC )
(Application for the courses fully funded by the Ministry of External Affairs, Government of India)

APPLICATION FORM

Application Id:2024COD000284
(To be submitted at the Indian Embassy: "KINSHASA")

Part- I

Nationality DEMOCRATIC REPUBLIC OF Name of INTEGRATION OF REMOTE SENSING,

CONGO Course GIS, DRONES AND AI IN AGRICULTURE
EXTENSION
Institute NATIONAL INSTITUTE OF Commencing From 26-02-2025 To: 11-03-2025
AGRICULTURAL EXTENSION
MANAGEMENT (MANAGE)

1. Personal Particulars

Name: MUSANGUSANGU AKAWA

Surname: GLODIE
Email: [email protected]
Sex: Female
Marital Status: Married
Date of Birth: 11-02-1996

Passport No: OP0660969 Issue Date: 09-01-2020

Valid Till: 08-01-2025 Place: kinshasa
Office Residence
Address croisement des avenues batetela et boulevard Laic 69 Bis, Quartier 12 C/Ndjili
du 30 Juin, Kinshasa/Gombe
Telephone No. -- --
Mobile/Cell - 00243-813029999
Fax -- --
Email [email protected] [email protected]

Special Dietary needs, if any:

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Person(s) to be notified in case of Emergency

Official Contact Peronal/Family Contact

Name jose ILANGA Ngonzimwiki
Address croisement des avenues batetela et boulevard Laic 69 Bis, Quartier 12 C/Ndjili
du 30 Juin, Kinshasa/Gombe
Tel Nos -- --
Mobile/Cell 00243-847233375 00243-850523554
Fax -- --
Email [email protected] [email protected]

Educational Qualification(s)

Degree / Diploma / Certificates Year Name of Educational Institute

Degree International Protocol and 2019 Universite de Kinshasa
Diplomacy

Professional Qualification(s), if any

Professional Qualification(s) Year Name of Institute

2. Details of Employment/Profession (current & previous)

Name of Employer Position Year Nature of Work

kin wifi executive From: 2017 To: 2018 in charge of customers

Present Employment Category: Government

Details of Current Employer

Name Ministry of agriculture and food security

Current Employer croisement des avenues batetela et boulevard du 30 Juin
Address
Current Email Id [email protected]
Current Phone 00243-84-7233375
Number
Current public relations experts
Designation
Current Work supervisng farmers organization
Responsibilities
Working Since 27-09-2018

3. Have you ever attended a course sponsored by the Government of India? No

3.1 If answer to 3 is yes, details of the Course (s):

Name of Course Institute Year of Passing

4. Details of Course(s) attended, if any, outside your country: No

4.1 If answer to 4 is yes, details of the Course (s):

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Name of Course & Country Year Sponser
Duration

5. Description of (a) qualification/experience related to the course applied for (b) reason (s) for applying
for this training course

learn indian experience in integrating remote sensing, GIS, drone and AI in extended agriculture.

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6. Certification of English language proficiency (by Indian Mission/Designated Authority)

Level Remarks
Spoken
Written

Mother tongue / Native

language:
Other language(s), if:
English Language test
administered by
Name
Adress
Telephone No. --
Email

Date Signature

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 Medical Report

(i) Name of the Applicant MUSANGUSANGU AKAWA

(ii) Age 28
(iii) Sex: (Male / Female) Female
(iv) Height (cm) 168
(v) Weight (kg) 68
(vi) Blood Group O+
(vi) Blood Pressure
(viii) Blood Sugar (Pre-prandial) : ( Peak post- prandial) :
1. Is the person examined in good health at present
?:
2. Is the person examined physically and mentally fit
to carry out intensive training away from home?
3. Is the person free of infectious diseases
(tuberculosis, trachoma, skindiseases etc.)?
4. Has the person taken Yellow Fever inoculation (in
case of peoplecoming from Yellow Fever region or
aslaid out in WHO Regulations)
5. Does the person examined have any chronic -
ailment which mayrequire regular
treatment/medication during the course?
6. List of any observed abnormalities indicated in
the chest X ray.
7. Does the person require any special assistance
tocarry out his daily activities? If yes, please specify

I certify that the applicant is medically fit to undertake a training course in India.

Name of Doctor/Physician
Registration No.
Address of Clinic / Hospital
City / Town
Telephone --
Email
Date

Signature of Doctor/Physician Seal of Clinic/Hospital

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 UNDERTAKING BY THE APPLICANT

I MRS MUSANGUSANGU AKAWA GLODIE of DEMOCRATIC REPUBLIC OF CONGO certify that information
provided by me in this form is true, complete and correct.
I also certify that :-

(i) I have read the course brochure and that I am aware of the course contents and living conditions in India.*

(ii) I have sufficient knowledge of English to participate in the training programme.

(iii) I am medically fit to participate in the Course and have submitted a medical certificate from the designated
doctor.

(iv) I have not attended any programme previously sponsored by Government of India.

(v) I have not applied for or am not required to attend any other training course/conference/meeting etc. during the
period of the course applied for.

If accepted for the ITEC training programme, I undertake to:

(a) Comply with the instructions and abide by Rules, Regulations and guidelines as may be stipulated by both the
nominating and sponsoring Governments in respect of the training;

(b) Follow the full and complete course of study/ training and abide by the Rules of the University/Institution/
Establishment in which I undertake to study or undergo training;

(c) Submit periodic assessments / tests conducted by the Institute (progress report which may be prescribed);

(d) Refrain from engaging in political activity, or any form of employment for profit or gain;

(e) Return to my home country at the end of the course of study or training;

(f) I also fully undertake that if I am granted a training award, it may be subsequently withdrawn if I fail to make
adequate progress or for other sufficient cause determined by the host Government.

(g) I confirm that I will not travel to India to attend the Course applied for in case I am pregnant - (for lady
participants).

Date:

Place:

(SIGNATURE OF THE APPLICANT)

Name:

* Details of the course are on the website of the Institute or can be obtained from them through e-mail.

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 Part - II

To be completed by the authorized official of the Nominating Government/ Employer

on behalf of the Government of DEMOCRATIC REPUBLIC OF CONGO certify that:

(a) I have examined the educational, professional and other certificates quoted by the nominee in Part-I of this form
and I am satisfied that they are authentic and relate to the nominee.

(b) I have gone through the medical certificates and X-ray reports produced by the nominee which state that he/she
is medically fit and free from any infectious disease and Yellow Fever and that having regard to his/her physical
and mental history there is no reason to indicate that the nominee is other than fit to undertake the journey to India
and to undergo training in India.

(c) The nominee has adequate knowledge of spoken and written English to enable him/her to follow the course of
training for which he/she is being nominated

(d) The nominee has not availed of ITEC training facilities earlier in India.

I nominate MRS MUSANGUSANGU AKAWA GLODIE on behalf of the Government of DEMOCRATIC REPUBLIC
OF CONGO as employer.

Name of Nominating Authority:

Designation:

Address:

Signature
(With seal)

Date:

Place:

Name and Designation (in block letters)

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