NATIONAL YOUTH COMMISSION INTERNATIONAL PROGRAM

APPLICATION FORM

Not for Sale – May be reproduced

INTERNATIONAL PROGRAM APPLYING FOR:

 URL of Facebook Profile: ________________________________________________________

1. Surname: _______________________________ 2. Gender: [ M ] [ F ] Passport-sized photo

First Name: _______________________________ 3. Height: ________

Middle Name: ______________ 4. Weight: ______5. Age:_______________

Nickname: ___________ 6. Birthdate: __________________7. Birthplace: __________________

8. Current Address: ____________________________________________________ 9. Region:____

10. Years of Stay: ________________ 11. Tel. No. (Landline/Area Code):_______________________

_______________________
12. Zip Code: _____ 13. Email Address: _________________14. Cellphone No: ________________ Pls. Indicate date taken

15. Religion: __________________16. Present Occupation/Position: _________________________ Date Taken:

17. Name of Office: ________________ 18. Office Address: ________________________________

19. Years in the Present Work: __________________ 20. Civil Status: _______________________

21. Number Place of Issue:

Passport Details 22. Type Official General

23. Date of Issue

24. Date of Expiry

25. Name (Relationship): 27. Phone:

28. Mobile Phone:
Emergency Contact
26. Address:

29. Father’s Name: Place of Birth: Occupation:

30. Mother’s Name: Place of Birth: Occupation:
31. No. of Brother/s:
32. No. of Sister/s:
33. Educational Background Name of School/University Course / Inclusive Dates Honors Received
Elementary
Secondary
Tertiary
Vocational
Post Graduate
34. Scholarship Grants Donor Inclusive Dates Honors Received

35. Are you a member of a (NYC Youth Organization Registration Program) YORP-registered organization? [ ] No [ ] Yes

If yes, please indicate name of organization: _______________________________________________________________

36. Youth Organization/Youth Serving Organization Affiliations:

Name of Organization Position Year Active Accomplishments

37. Special Skills or Talents:

38. Food Restrictions: 38. Allergies

39. Dialect(s) or Foreign Language(s) Spoken:

40. Title of Seminar/Training Course Attended Inclusive Dates No. of Hours Conducted by
41. Previous Work Experience

Name of Company Position Inclusive Dates Salary

42. Character References: [not related to you within the third degree of consanguinity]

Name Occupation Address and Telephone No.

All facts and data given in this information sheet will be treated with utmost confidentiality

43. Have you previously applied for any NYC International Exchange Program?  No  Yes How many times? ________________

If yes, please indicate the program/s and year/s: ________________________________________________________________________

44. Have you been a participant of any NYC International Exchange Program?  No  Yes How many times? _______________

If yes, please indicate the program and year: _______________________________________________________________________

If yes, have you submitted any of the following:

[ ] Post-Program Evaluation Form [ ] Terminal Report [ ] Article for Group Blog

Please indicate link of group blog (if applicable): _____________________________________________________________________

If yes, have you completed the 40-hour volunteer work requirement? [ ] No [ ] Yes

45. How did you know about the program?

Facebook: _____ Twitter: ______

Website: _____ E-mail from NYC: ______

Others [pls. Indicate]: _____________________________________________________

46. Have you availed of any program or scholarship grant offered by any foreign government? [ ] No [ ] Yes

If yes, please indicate the program, year, and name of organizer

47. Have you attended any seminar, conference or trainings abroad? [ ] No [ ] Yes

If yes, please indicate the program and year _______________________________________

48. Have you been involved with any NYC local program or activity? [ ] No [ ] Yes

If yes, please indicate the program(s) and year ______________________________________

49. Have you ever been convicted of any crime involving moral turpitude? [ ] No [ ] Yes

If yes, please indicate the nature and status

50. Do you have any pending case? [ ] No [ ] Yes

If yes, please indicate the nature and status

STATEMENT

I hereby certify upon my honor that all facts and information indicated herein are true and correct to the best of my knowledge. I further declare that
any information given by me that is untrue may constitute a disqualification to any NYC programs.

The undersigned expressly authorizes the National Youth Commission or its representatives to use, share, and process my personal information I
have provided, shared, or declared in this form for any lawful purpose.

Further, I subscribe and agree that the National Youth Commission has the sole prerogative to select and nominate the delegates to any
International Program, and its decision is final and executory.

IN WITNESS hereof, I am executing and signing this statement voluntarily without compulsion.

_____________________________
Signature

______________________________
Printed Name

NOTE:
 The National Youth Commission reserves the right and prerogative to exclude applicants who will not meet the minimum requirements of the
Program. Lack or non-compliance of any of the above stated requirements will mean automatic disqualification without notice.
 Mail or hand carry your application to the International Programs Unit, National Youth Commission, 3rd Floor, West Insula Building, 135 West
Avenue, Quezon City. Tel No. 4268733.
Please fill out the form legibly