Аспект

Work and Travel USA

Вітаємо вас на етапі реєстрації у програмі Work and Travel USA! Для нас дуже важливо знати, як ви дізналися про нас та про програму Work and Travel USA. Вкажіть один або декілька варіантів: - побачив оголошення/плакат у моєму ВУЗі - був присутній на презентації - отримав флаєр, буклет, листівку тощо - знайшов сайт в Інтернеті - знайшов інформацію «ВКонтакте» - чув рекламу по радіо - порадили друзі/знайомі/родичі - інше: Будь ласка, уважно заповніть всі поля анкети. Для заповнення анкети ви будете використовувати дані внутрішнього та закордонного паспорту, ідентифікаційний код, а також ви повинні знати адресу прописки та адресу фактичного проживання з індексом. Будь ласка, приготуйте ці дані перед заповненням. Після вдалого заповнення анкети на екрані з’явиться напис «Congratulations! You have successfully filled in the form. Thank You!» Бажаємо вам успіху!
Анкета на участь у програмі

Дані внутрішнього паспорту (заповнюється українською мовою):

u1: Прізвище

u2: Ім'я

u3: По батькові

u4: Серія та номер паспорту

u5: Коли виданий
Місяць: День: Рік:

u6: Ким виданий

u7: Область прописки

u8: Адреса прописки

u9: Ідентифікаційний номер

ЗАПОВНЮЄТЬСЯ ВИКЛЮЧНО АНГЛІЙСЬКОЮ МОВОЮ / TO FILL ONLY IN ENGLISH

PARTICIPANT APPLICATION

Sending Partner:

Aspect- Ukraine

e0.1: Start Date:

May 6 (17 weeks)
May 17 (15 weeks)
June 1 (13 weeks)
June 15 (11 weeks)
other:

e0.2: I would like to participate in the: (Choose one)

Full-Placed (FP) Option
Self-Placed (SP) Option

1. GENERAL INFORMATION: nformation MUST be written EXACTLY as in passport!

e1.1: Family (Last) Name:

e1.2: Given (First) Name:

e1.3: Sex:
Female Male

e1.4: Date of Birth:
Month: Day: Year:

e1.5: Place of Birth:

e1.6: Country of Birth:

e1.7: Country of Legal Permanent Residency:

e1.8: Country Issuing Passport:

e1.9: Emergency Contact:

First name:

Last name:

Middle name:

e1.10: Relationship:
(for example mother, father etc)

e1.11: Emergency Contact Telephone:
(For example: +380445011215)

e1.12: Current Address:

e1.13: City:

e1.14: Postal Code:

e1.15: Country:

e1.16: Telephone:
(For example: +380445011215)

e1.17: Mobile telephone:
(For example: +380675011215)

e1.18: Email:

Respondence is maintained through email. Each student must have a unique email address that is checked at least once a week. Students may not share email addresses.

e1.19: Other:
  vkontakte.ru:

  skype:

  icq:

  facebook.com:

2. EDUCATIONAL INFORMATION:

e2.0: When and where did you finish school

Year:

Location (City, town, village):

Region:

e2.1: Current University:

Current Grade of Study:

e2.2: Date of Matriculation:
Month: Day: Year:

e2.3: Date of Graduation:
Month: Day: Year:

e2.4: Status: Full Time

e2.5: My university break (Proof of Student Status) begins:
Month: Day: Year:

e2.6: My university break (regarding Proof of Student Status) ends:
Month: Day: Year:
(according to US Embasy Regulation)

e2.7: What are you currently studying in university?

e2.8: How do you personally rate your English level?

Excellent Good Poor

3. MEDICAL INFORMATION

e3.1: Do you have any health, physical or mental problems or limitations?
No Yes

If yes, please explain:

e3.2: Are you currently taking any medication:
No Yes

If yes, please explain:

e3.3: Do you have allergies?
No Yes

If yes, please explain:

e3.4: Is there any type of work you physically can not do?
No Yes

If yes, please explain:

4. INTERVIEW:

e4.1: Do you have a passport for travelling abroad?
No Yes

If yes, please insert number. If no, insert date when the passport is expected:

Passport issued by:

e4.2: Have you been in USA before?
No Yes

e4.3: If yes, please specify location ?

e4.4: Have you participated on the Work & Travel Program before?
No Yes

e4.5: If yes, please specify Year and Sponsor?
1: Year:     Sponsor:

2: Year:     Sponsor:

3: Year:     Sponsor:

4: Year:     Sponsor:

e4.6: Do you have relatives in USA?
No Yes

e4.7: If yes, please specify ?

e4.8: Relationship:

e4.9: Location (state, city):

e4.10: Please specify minimum one work experience
Work experience 1
  Start date: Month Year

  Finish date: Month Year

  Position Name

  Company Name

  City

  Country

Work experience 2
  Start date: Month Year

  Finish date: Month Year

  Position Name

  Company Name

  City

  Country

Work experience 3
  Start date: Month Year

  Finish date: Month Year

  Position Name

  Company Name

  City

  Country

e4.11: Please list your skills: (at least two of them)

e4.12: What hobbies do you have? (at least two of them)

e4.13: What interests do you have?(at least two of them)

e4.14: Please list your achievements:(at least two of them)

e4.15: Shortly describe your personality:(at least two of them)

5. ADDITIONAL INFORMATION:

e5.1: Do you have a roommate request?

	His/her (first / last name)	Relationship to you?
1.
2.

Personal Information:
Please provide information about yourself so that we may place you with the employer who most suits your interests!

e5.2: What are your main goals or reasons for participating in Work & Travel Program

1.
2.

e5.3: Do you smoke?
No Yes

e5.4: Can you snow ski?
No Yes

e5.5: Can you swim?
No Yes

e5.6: Are you life-guard certified through Red Cross?
No Yes

e5.7: Are you CPR certified through Red Cross?
No Yes

e5.8: Do you have an International Driver's License?
No Yes

e5.9: Are you willing to drive in the US?
No Yes

e5.10: Do you have visible piercing (except earrings)?
No Yes

e5.11: Do you have visible tattoos?
No Yes

e5.12: Preferred Type of Work:
Please indicate the type of work that you would prefer/not prefer to do while on the program. Please be advised that we cannot make guarantees, but will make every effort to accommodate your request!
You can mark maximum 3 fields as "not acceptable"
Hotel Housekeeping/Laundry
No Yes

Kitchen/Restaurant/Server
No Yes

Front Desk/Reception/Hostess
No Yes

Agricultural
No Yes

Alaska seafood factory
No Yes

Amusement Park
No Yes

Swimming Pool/Lifeguard
No Yes

Camp/Outdoor work
No Yes

Physical Labor
No Yes

Resort/Casino
No Yes

Supermarket
No Yes

Retail
No Yes

Maintenance
No Yes

Concessions
No Yes

Factory
No Yes

Preferred other work:

By SUBMITTING this form I confirm that all mentioned above information is correct. I understand that any further changes can affect additional charges or program cancellation without refund.

By SUBMITTING this form I confirm that I can read, understand and sign documents formulated in English.