Application Form (Bewerbungsformular) Unpaid Work Experience. Incoming (Aufnahme)

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1 Application Form (Bewerbungsformular) Unpaid Work Experience Incoming (Aufnahme) PERSONAL INFORMATION Family Name Date of Birth Country Sex (!) Male Female City PERIOD OF TI M E First Name Address SKYPE Name Post Code Profession Beruf (in English and German) Passport / ID Number Please add copy of passport/id! (Personalausweis Kopie beilegen) Status (!) Trainee Young Professional Telephone Mobile Do you have a driving license? (!) No Do you have a police record? (!) No WHO SHOULD WE CONTACT IF THERE IS AN EMERGENCY? Name Relationship Address City Post Code Country Telephone Mobile

2 Information How did you hear about our association? (Wie sind Sie auf unsere Organisation aufmerksam geworden?): YOUR HEALTH bitte in Englisch und Deutsch ausfüllen Do you have any special dietary needs or principles? (Haben Sie spezielle Bedürfnisse oder Prinzipien im Bezug auf die Ernährung?) (!) No If yes, please tell us about them: Do you have any allergies? (Haben Sie Allergien?) (!) No If yes, please tell us about them: Do you have any special or cultural needs? (Haben Sie spezielle oder kulturelle Bedürfnisse?) (!) No If yes, please tell us about them: Do you Smoke? (Rauchen Sie?) (!) Do you have any current or historical medical conditions we should be aware of? (Haben oder hatten Sie Erkrankungen, von denen wir wissen sollten?) (!) Are you taking any regular medication? (Nehmen Sie regelmäßig Medikamente?) (!) Are you receiving any medical treatment? (Sind Sie in ärztlicher Behandlung?) (!) Do you have any mental health problems? (Leiden Sie unter psychischen Problemen?) (!) No

3 HEALTH DETAILS SECTION Please detail any form of medicine, drugs or treatment you are currently and/or regularly receiving. (Bitte führen Sie die Medikamente oder Behandlung auf, welche Sie zur Zeit und/oder regelmäßig erhalten) Please advise of any allergies or diseases you suffer from. (Bitte führen Sie Ihre Allergien oder Krankheiten auf, unter denen Sie leiden) Please advise of any operations or major illnesses suffered in the last 3 5 years. (Bitte führen Sie Operationen oder schwere Krankheiten der letzten 3-5 Jahre auf) Please advise of any ongoing medical problems. (Bitte weisen Sie uns auf laufende medizinische Probleme hin.)

4 YOUR WORK PLACEMENT REQUIREMENTS Please state the business area in which you are training.(e.g. marketing, waiter, electronic engineering, Barman) Please describe the kind of work you would like to do? (e.g. working in the marketing department of a company involved in public relations) Other than improving your English, what are your expectations concerning the training, what skills and knowledge would you want to use whilst in your placement and what are your motivations for undertaking this experience? Language Skills Please list any languages you can speak, indicating your level and the number of years of study Mother tongue? English Oral comprehension (!) Nil Fair Good Fluent Speaking ability (!) Nil Fair Good Fluent Number of years study years Other Languages #1: Nil Fair Good Fluent #2: Nil Fair Good Fluent #3: Nil Fair Good Fluent

5 Do you require? : We will inform you about additional costs. Airport Transfer Flughafen-Transfer vor Ort (!) No Language course 1st week Sprachkurs in der 1. Woche (!) No Half Board Accomondation Verpflegung (Frühstück + Abendessen) (!) No Buss-Pass Ticket öffentliche Verkehrsmittel (!) No YOUR HOBBIES AND INTERESTS Please tell us a little about your hobbies, interests and what you do in your spare time: PARTICIPANT DECLARATION I certify that the information I have given in connection with this application is true and correct. I give my permission to Europäischer Bildungsverbund e.v. to use this information and other documents I have enclosed to fulfill my requirements and agree to this information being passed to other people and organisations as necessary. Signed : Name: Date: Rücksendung per oder Post an: Europäischer Bildungsverbund e. V. Büro-/Postanschrift: Steinfeldstraße 3, Barleben Kontakt: Jacqueline Sell j.sell@e-b-v.eu Telefon Imagefilm: