INTERNSHIP APPLICATION, 2017

All applicants are required to read the instructions and information before completing the application.

SECTION A: PERSONAL INFORMATION

  1. NAME

LastFirst Middle
2. a. PERMANENT ADDRESS
2 b. MAILING ADDRESS (If Different from 2a, please state mailing address)
3. DATE of BIRTH ____/______/_____ 4. GENDER  MALE  FEMALE
dd mm yyyy
5. NATIONALITY: ______Dual: yes/no, If yes other nationality______
6a. National ID# / 6b.Type (Passport) / 6c. Passport Number: / 6d. Driver’s Permit
7. PERSONAL CONTACT INFORMATION
Home #: Mobile#:
Work #: ext Email Address:
8. EMERGENCY CONTACT INFORMATION (Indicate individual to contact in case of emergency)
NAME:
Last First Middle Relation to Applicant
Home #: Mobile#:
Work #: Ext: Email:
9 a. SECONDARYLEVEL- Please include number of secondary subjects attempted and passed with grade 3 and above.
Name of Institution / Examining Body/Level / Number of Subjects passed (Grade 3 or C and above) / Date Awarded (Month Year)
9 b. TERTIARY LEVEL- What year will you be going into for the 2017-2018 academic year?  1st Year  2nd Year  3rd Year  graduate school other ______Please indicate your major, minor and current GPA
Date From To / Name of Institution / Major/ Minor / GPA
mm/yyyy / mm/yyyy
9 c. AWARDS and AFFILIATIONS- Please list all certificates, awards and clubs of which you are a member.
1. / 2.
3. / 4.

All Applicants are required to read the instructions and information before completing the application.

SECTION B: ACADEMIC AND CAREER OBJECTIVES

10. WORK and /or RESEARCH EXPERIENCE:(Please attach a Resumé or Complete the Table)

DATE / JOB TITLE/ ACTIVITY / EMPLOYER/ ORGNIZATION NAME & ADRRESS / MAIN TASKS/ RESPONSILIBITIES
From mm/yyyy / To mm/yyyy

11. REFERENCES:Please attach the Name, Position, and Contact information of at least two referees

12. PROGRAMME OF CHOICE: After reading the description of each Research Project, please choose one

□Trinidad & Tobago Microzonation Project
□Patterns in Pre-Explosion Seismic Data (MVO)
□Strengthening UWI-SRC Student Outreach
□ Design of Seismic Data Acquisition Modules

13. Computer and/or Research Skills: Please state your computer skills and programmes used.

14. Career Objectives

Please describe the reasons for your interest in the programme and what value you think you can add to the SRC. Include activities or events that influenced your specific career interests and academic goals. (Use an additional sheet if necessary, 2000 word limit)

  1. Declaration and Signature

I hereby certify that the information that I have provided is accurate. Any misrepresentations will result in my termination from the internship.

______/______/______

SIGNATURE of APPLICANT DayMonthYear