COUNCIL OF INTERNATIONAL FELLOWSHIP
(C.I.F.)

APPLICATION FORM FOR A CIF PROGRAM
IN      
(Indicate Country of choice)

Please attach 4 photos here
Print your name 
on back
Fill in the grey fields – more than one line can be used for every question!

FAMILY NAME:        MALE    FEMALE 
(as stated on the official identification) 

FIRST NAME:        MIDDLE NAME:      

BIRTH DATE: YEAR        MONTH        DAY      

PLACE OF BIRTH:        COUNTRY      

POSTAL ADDRESS (as used in your country):      

E-MAIL ADDRESS:      

PHONE: HOME        OFFICE        FAX:      

PROFESSION:      

PRESENT CITIZENSHIP:        FORMER CITIZENSHIP (if applicable):      

PASSPORT NUMBER:      

IDENTITY CARD NUMBER:      

FAMILY SITUATION:      

RELIGION (optional):      

INFORMATION ABOUT A CONTACT PERSON IN CASE OF EMERGENCY:

FIRST AND FAMILY NAME:      

ADDRESS:      

PHONE:        Mobile Phone:      

E-MAIL:        Relationship to Applicant:      

HEALTH CONDITIONS:

Give description and details of any particular problem such as disability, treatment, allergy, phobia, etc.:
     

Do you have dietary restrictions	YES    NO 

If yes, what:      

Give details about your health insurance during the program:      

Do you have food preferences (for example vegetarian food, etc.) 	YES    NO 

If yes, what:      

Do you smoke? 	YES 		NO 

EDUCATION: Start with the highest degree received, indicating study dates (from–to)	
Title	School/Institution	Years	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

PROFESSIONAL TRAINING:
Give any detail about the kind of training, the date, and the place:
     
     
     
     
	
PREVIOUS JOBS:	
Date	Job title	Agency	
     	     	     	
     	     	     	
     	     	     	
     	     	     
	
PROFESSIONAL SITUATION:
Position and title of your present job:      
	
When were you appointed?      
	
Name and address of your agency:      
	
Purpose and function of your agency:      
	
What professional methods does it use?      
	
Give details about your work on a separate sheet, if necessary, according to the following points:

1. Who are your clients?      	

2. How are they referred?      	

3. How old are they?      
	
4. How do you work with them?      	

5. Description of your main responsibilities?      
	
DESCRIPTION OF OTHER RESPONSIBILITIES RELATED OR NOT RELATED TO YOUR WORK
(such as teaching, volunteer work, etc):
     
     
	
Have you already been a participant of, or accepted to, another CIF/CIPUSA exchange program?
YES 		NO 
If yes: Year:        Country        Did you participate? YES   NO 
If you participated, give details about the kind of placement:      
	
Explain how you were informed about the CIF programs:
     
	
GIVE DETAILS ABOUT YOUR MOTIVATIONS FOR APPLYING TO THIS CIF PROGRAM.
30 lines can be used below. Us a separate sheet, if necessary
     
	
FIELD PLACEMENT REQUEST:
Give details about the kind of agency, population, methods and professional position you would like to observe:

1. Choice:      

2. Choice:      

3. Choice:      
	
If your choice is different from your work, explain why:      
	
If CIF cannot organise a program of your first choice, do you prefer to postpone your participation to another year?
YES 		NO 	
Besides your main field placement, is there any other specific field you would like to know about?
     
     
	
WORK/FINANCIAL INFORMATION:
Will you get leave of absence to attend this CIF program?	YES 		NO 	
Will you go back to your present position after the program?	YES 		NO 	
Will you get the total amount or part of your salary during the program? 	YES 		NO 	
Who will pay your travel expenses?      	
Do you live in a country with currency restrictions?	YES 		NO 
If yes, what is the maximum amount of foreign currency that you can bring with you?      
	
Do you have any relatives or friends in the country of the program?	YES 		NO 
If yes, where?      
	
KNOWLEDGE OF THE LANGUAGE OF THE PROGRAM:	
Language:      		FAIR	GOOD	EXCELLENT	
	Reading				
	Writing				
	Speaking				
	Understanding				
Do you speak any other language?      
If yes, give details:      

PREVIOUS MAIN VISITS ABROAD:	
Country	Year	Purpose	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

What are your hobbies or leisure time interests?
     
     
	
Have you applied to any other CIF-program this year? 	YES 		NO 
If yes, which?      

Statement by the applicant to read carefully before signing below:
I certify that the information given in this application is complete and accurate and that I have not participated in a CIF/CIPUSA Program within the last three years.

I certify that I subscribed to a health/accident insurance policy covering all expenses, which may occur during the program, and hereby relieve CIF/CIPUSA of all liability for such.

I understand that this information will be shared with CIF International (National Branches and Contact Persons)

I commit myself to fully participate in the program, and I understand that with regard to the issuance of the visa I will depend on the conditions of the country I will be travelling to.

I agree that as a participant the following information will be placed on the Participants Directory which is for internal use only:

Name, Male/Female,  Country, Postal Address, E-mail Address,  Phone Home & Offoce, Fax 

 ________________                                                                           ________________________                                                                             
DATE		SIGNATURE

RETURN COMPLETED FORM TO YOUR OWN NATIONAL CIF BRANCH, WHERE ONE EXISTS, otherwise to the CIF Branch in THE COUNTRY of the program.

Addresses of CIF National Branches can be found on: www.cifinternational.com