Personal Information

ID-Card *  ( เลขที่บัตรประชาชน )

First Name * Last Name * Nickname *

ชื่อ *  นามสกุล * ชื่อเล่น *

โทรศัพท์บ้าน มือถือ * อีเมล์ *

ที่อยู่    รหัสไปรษณีย์ 

เชื้อชาติ สัญชาติ ศาสนา

Age Date of Birth (month/day/year) -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -19811982198319841985198619871988198919901991 City of Birth

Sex : Male Female Status : Married Single Other

Any brothers or sisters

Father's occupation Mother's occupation

Do you smoke ? Yes      No      Do you have driver's license ? Yse      No     

ชื่อ - นามสกุล ความสัมพันธ์

โทรศัพท์บ้าน มือถือ อีเมล์

ที่อยู่

Education

Are you presently a Full Time Student ? Yes      No      

Year of study 1^st   2^nd   3^rd   4^th      GPA

Name of University*

Major field of study Faculty

Have you taken TOEFL Test ? Yes      No      Other      Score

Other Language spoken

Hobbies and Interests

Computer program you can operate :

Travel Experiences

Have you participated in a J-1 Program before ?      Yes      No          What year ?

Have you been to the USA before ?      Yes      No          If yes, When ? Where ?

Have your visa application to the USA ever been rejected ?      Yes      No

Work Experience

Do you have any work experiences ?      Yes      No     if Yes, please fill

Company Position From -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -2002200320042005200620072008200920102011201220132014 To -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -2002200320042005200620072008200920102011201220132014

Company Position From -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -2002200320042005200620072008200920102011201220132014 To -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -2002200320042005200620072008200920102011201220132014

What is the Start and End date you would be able to travel to the USA During Your university Break ?
Start Date -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -200820092010201120122013      End Date -JanFebMarAprMayJunJulAugSepOctNovDec -01020304050607080910111213141516171819202122232425262728293031 -200820092010201120122013

Why do you interest Work & TRavel program ?

What is you expect from Work & Travel program ?

Health

Do you have any allergies or health problems that will affect your ability to work ?       Yes      No

Have you had any health problems or Surgeries in the past ?      Yes      No

Have you ever received psychiatry care ?       You      No

How did you know American Learning Co.,Ltd ?

Why do you interest in Work & Travel Program ?