Partner: Objectives and Benefits Target audiences Eligibility Contact Forms
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Work and Travel Student Application
Please fill in the following information
All boxes must be completed
Incomplete applications will not be accepted
Application for:
Student ID Number (office use only)
Preferred Program Begin Date:    
Preferred Program End Date:    


1. General Information (as it appears on your passport)
Family Name:    
Given Name:    
Middle Name    
Gender:    
Birth date:    
City of Birth:    
Country of Birth:    
Citizen of:    
Legal Permanent Resident of:    
Passport Number:    
Issuing Country    
Date of Issue:    
Expiration Date:


2. Contact Information
Present Street Address:    
City:
Zip/ Postal Code:
Country:
Permanent Street Address:    
City:    
Zip/ Postal Code:    
Country:    
Phone Number:    
Mobile Phone Number:    
Fax Number:    
Best time to call:    
Country Telephone Code    
Email Address:    


3. Emergency Contact Information
Name:    
Phone Number:    
Alternate Phone Number:    
Relationship:    
Country:    
English Speaking?    
yes
no
If no, what language?    


4. Criminal Background
Have you ever been convicted of a crime?    
yes
no
If yes please explain:    


5. Program Information
Program Length Desired:    
Preferred Arrival Date:    
Preferred Departure Date:    
Months:    


6. Please list your reasons for participating in this program
Please list your reasons for participating in this program:    


7. Previous Work Experience:
Company:    
What did you do there?    
Time Period:    
Company:    
What did you do there?    
Time Period:    
Company:    
What did you do there?    
Time Period:    
Special Skills:    
Name of College/University you attend    
(Please attach a certificate of enrollment)    




8. Language Skills- Please list languages you have known/studied and rank your proficiency (Excellent, Good, Fair, Poor).
Language    
Years Studied    
speaking    
reading    
writing    
Other language:    
Years Studied:    
speaking    
reading    
writing    
Other language:    
Years Studied:    
speaking    
writing    


9. Hobbies
Please list hobbies, interests, sports in which you are interested:    


10. Health Background
Allergy (if serious):    
yes
no
Asthma:    
yes
no
Cancer/Tumors:    
yes
no
Chicken Pox:    
yes
no
Convulsive Disorder:    
yes
no
Diabetes:    
yes
no
Dyslexia:    
yes
no
Eating Disorder:    
yes
no
Eczema:    
yes
no
Hepatitis:    
yes
no
Measles:    
yes
no
Migraine Headaches:    
yes
no
Mumps:    
yes
no
Physical Handicap:    
yes
no
Psychological Disorder:    
yes
no
Rheumatic Fever:    
yes
no
Rubella:    
yes
no
Scarlet Fever:    
yes
no
Substance Abuse:    
yes
no
Thyroid Disease:    
yes
no
Ulcer:    
yes
no
Urological Problems:    
yes
no
Whooping Cough:    
yes
no
If yes to any of the above, are any of the conditions serious enough to warrant treatment or require special consideration?    
no
yes please explain below
Warrant treatment or special consideration:    
Will you be required to take any prescription medication(s) during your stay?    
no
yes please explain below
Please specify which medication(s) and for what condition(s)    


 
I certify that the information provided is true and complete to the best of my knowledge.    
I agree
I disagree

(*) are required