ec council application form

7/29/2019 EC Council Application Form

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Information Security Training Sponsorship Program

Application Form

Name

E-mail

Mailing Address

CountryTelephone / Fax

Employer

Job Designation

Working Experience (Please attach your resume)

Please indicate preferred course

Please select the mode for course

Name of Referee

Designation

Department

Telephone / Fax

Email

Relationship

CoursesMode

iLearn iVideo iClass

Network Security Administrator (E|NSA)

Certified Ethical Hacker (C|EH)

Computer Hacking Forensic Investigator (C|HFI)

Certified Security Analyst (E|CSA)

Certified Disaster Recovery Professional (E|DRP)

EC-Council Secure Programmer (EC|SP)

EC-Council VOIP Professional

Note: Please complete the application form using this pdf, hand written form will not beaccepted. Please obtain referee's or company's original stamp.

Print


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Important Notes:Criteria for Sponsorship

1. EC-Council scholarship will be awarded to recipients from IMPACT partner countrieswith good background or work experience in cybersecurity or information technology

2. Trained candidate must attempt for certification within 6 months after the training andwithin 12 months from activation of self-study classes

3. Requesting organisation and sponsored candidate to provide testimonies or work withEC-Council for any public relations activities when the need arises4. Organisations and candidates will allow EC-Council to share certification details of the

candidates to EC-Council or IMPACT

Declaration by Applicant:

I hereby declare that:

1. All the information given in this Application Form and all the documents submitted arecomplete, true and correct. I authorise the Foundation to verify the information fromwhatsoever sources and by whatever means that EC-Council or IMPACT deemsappropriate

2. I understand that EC-Council or IMPACT reserves the right to forfeit my eligibility for theScholarship or revoke

3. Any Scholarship approval granted to me or recall any scholarship granted to me in theevent that:

a) any of the information, statement or fact disclosed in this Application Form isfalse or incorrect; or

b) if there is any misrepresentation of information, statement or fact in this Application Form; or

c) if any of the documents submitted in support of this application is falsified or forged

4. I do not have any criminal record

5. I understand and accept that EC-Council or IMPACT reserves the right and has theabsolute discretion to approve or reject my application without assigning any reasonwhatsoever and I accept all decisions by EC-Council or IMPACT as final and conclusive

6. EC-Council or IMPACT shall not be held responsible for any loss or delay in respect tothis application

Signature of Applicant

...........................................................Date:

Please email completed application form and supporting documents to: [email protected]

IMPACTJalan IMPACT63000 Cyberjaya, Malaysia

Tel: +60 (3) 8313 2163Fax: +60 (3) 8319 2020Contact Person: Hamnar Dooply www.impact-alliance.org


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Information Security Training Sponsorship Program

Letter of Recommendation

(DATE)

Manager, Training & Skills DevelopmentInternational Multilateral Partnership Against Cyber Threats (IMPACT)Jalan IMPACT63000 Cyberjaya

Selangor Darul EhsanMalaysia.

Dear Sir,

Re: Recommendation for Information Security Training Sponsorship Program

With reference to the Information Security Training Sponsorship Program, we would like toendorse our support and recommend the following person from our country to participate in thisprogram:

Name of Applicant:

Address:

Contact details:

Yours faithfully,

Name of Referee:

Designation:

ec council application form

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