Attach a recent good quality
head and shoulders photograph (5 cm x 6.5 cm) (2 “ x 2 1/2")
“Smile”
If possible, photograph should be in color and show you smiling (Suggestion: Secure additional copies - they can all be put to good use for passport, newspapers, gifts, etc.)
Rotary Intercountry
Teacher Exchange
(R.I.T.E.) Application
Before completing this application, please read the current R.I.T.E. brochure. This
publication offers a general overview and mission statement of the R.I.T.E. program.
Candidates should be fully aware of the objectives of the program before applying.
Name in full: ______Please print or type. Do not use initials. Underline family name
Male ____ Female ____ Date of Birth ______(For host district use)
day month year
Mailing Address: ______
Number and Street Ciy/Town
______ State/Province Country Postal Zip Code
Telephone: ______Home Office FAX E-mail
Country of Citizenship ___ Country of Birth: ______
Person to notify in case of emergency (relationship, name, address and phone number): ______
______
Marital status (For host district use)
If married, spouse’s name and address: ______
Children: How many Names and ages: ______
EMPLOYMENT RECORD: List current employment first (must be full-time)
1.______
Name and address of employer
______Period of employment Title/Duties and responsibilities
2. ______
Name and address of employer
______Period of employment Title/Duties and responsibilities
3. ______
Name and address of employer
______
Period of employment Title/Duties and responsibilities
4. ______
Name and address of employer
______
Period of employment Title/Duties and responsibilities
NOTE: A brief resume may be attached
R.I.T.E. Applicant’s Educational Data (academic, technical, professional)
1. ______Name and location of institution Dates attended Degree obtained and dates received
2. ______
Name and location of institution Dates attended Degree obtained and dates received
3. ______
Name and location of institution Dates attended Degree obtained and dates received
Language: List languages (other than your own) of which you have knowledge, proficiency in reading, writing, and speaking:
List countries that you have visited and length of stay: ______
______
Describe any disability/handicap or allergy:______
Describe your hobbies and/or special interests: ______
List educational, fraternal, civic, professional and other organizations of which you have been a member. Indicate offices held.
____
Why do you want to participate in the R.I.T.E. program? How will this experience benefit you and your students? ______
(Use additional sheets if necessary)
Where did you hear about the R.I.T.E. program? ______
ROTARY CLUB ENDORSEMENT
The Rotary Club of proposes ______
and forwards his/her application for consideration by the District R.I.T.E. subcommittee:
______
Club President’s name (please print) Club President’s address (Please print)
______
Club President’s signature Date Club phone/FAX/e-mail
Be sure the teacher’s $25 non-refundable application fee (payable to R.I.T.E.) is enclosed.
DISTRICT ENDORSEMENT
(Number)
has been selected to be a member of our district’s R.I.T.E. Exchange Team. The R.I.T.E. subcommittee did/did not have a personal interview with this candidate. A total of applications were received and considered by the clubs of the district in making their selections. A total of applications were endorsed and forwarded to the district by sponsoring clubs.
______R.I.T.E. Chairman’s name (please print) Address
______R.I.T.E. Chairman’s signature Date Phone/FAX/e-mail
R.I.T.E. - Application - EN Revised 4/99