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Summer Work and Travel USA 2011 Program
PERSONAL INFORMATION:
Family Name (as in passport): __________________________________________________
First Name: (as in passport) ____________________________________________________
Middle Name/Patronymic: _____________________________________________________
Birth Date (day/month/year): _____/_____/________
Present Address ____________________________________________________________
City: _____________________________ Country: _________________________________
City of Birth: ______________________ Country of Birth: ____________________________
Citizenship: ________________________________________________________________
Phone number: 8 (______)_____________Mobile phone number: +7 (_____)____________
E-mail: ____________________________________________________________________
University Name: ____________________________________________________________
Department/Faculty: _________________________________________Year ____________
University entered date _______________ Expected graduation date __________________
Your English Level: (Basic/Conversational/Fluent) __________________________________
Passport number: __________________________ Student ID number _________________
Your best friend’s name and mobile phone number: _________________________________
QUESTIONS:
Have you participated in Work and Travel Program before? __________________________
Have you ever been abroad? Where? ___________________________________________
How did you hear about Work and Travel Program? ________________________________
__________________________________________________________________________
__________________________________________________________________________
Why do you want to participate in Work and Travel Program? _________________________
__________________________________________________________________________
__________________________________________________________________________
Do you have any Work Experience? _____________________________________________
__________________________________________________________________________
__________________________________________________________________________
Are you independent person? __________________________________________________
__________________________________________________________________________
__________________________________________________________________________
What is Life Experience for you? ________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do you have any problems with your health? ______________________________________
__________________________________________________________________________
__________________________________________________________________________
Have you ever been denied US Visa? ___________________________________________
__________________________________________________________________________
__________________________________________________________________________
Date: _____________ Signature: __________________
FOR OFFICE USE ONLY | Accepted/Denied by __________________________________
WT Agreement number ________________________________
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