Application Form 2019: International Youth Exchange
Application Form 2019: International Youth Exchange
Widowed Divorced
Number Type of Passport
Private Diplomat Official
Passport
Date of Issue Date of Expiry
(Day) (Month) (Year) (Day) (Month) (Year)
Address
Current Address
Tel: Fax:
Mobile: E-mail:
Full Name Relationship
Address
Contact Person
in Emergency
Tel: Fax:
Mobile: E-mail:
Profession/Occupation:
Full Name Relationship
*If you do not have phone
at your current address,
please write contact
person and number. Phone Number: E-mail:
2. Health Condition
Blood Type A B O AB UNKNOWN
Good
□Having Chronic disease
Please specify:
Health Condition
_________________________________________________________________________
_________________________________________________________________________
Dietary □None
Requirements □Vegitarian □Vegan □Halal □Others ( )
Other Allergies and □None
Restriction □Dogs □Cats □House dust □Others ( )
Information of your
School/University/ Field of study/ Positions
Employer
English Proficiency
certificated score (if any, e.g. TOEFL)
Level of English
Speaking : Good Fair Poor
Language Writing : Good Fair Poor
Reading : Good Fair Poor
Other
Language
4. Personal Activities
Activities Period of Involvement
Sports/Clubs
Hobbies
Awards
(if any)
5. Essay
Declaration
I hereby certify that the filling in and statements by myself in this form are true and correct.
I am fully aware of my responsibilities as participant.
I will follow all of the guidelines given for this activity and will not hold the facilitator or organization responsible
for any untowards incident that i have caused or incured.
(Day) (Month) (Year)