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APPLICATION FORM
Your application must be accompanied by 2 passport size photos.

PART 1

A. GENERAL INFORMATION
1. Name: (Last-First-Middle)
Address:
City/State/Zip code
Telephone: (Home): (please include area code)
Telephone: (Work) : (please include area code)
Fax :
E-Mail :
2. Social Security Number:
(Chilean residents only) C.I. # :
3. How much notice do you require before departure?
4. When are you available to come to Chile?
5. What is your reason for coming to Chile?


B. PERSONAL INFORMATION
1. Age:
Date of Birth:
2. Sex: Male Female
3. Marital Status: Single Married Separated Divorced Widowed Engaged
Length of Status:
Is your partner also applying? Yes No
4. Dependents:
Name:
Relationship:
5. Citizenship:
U.S. or CAN. Resident: Yes No
Do you have a valid passport? Yes No
Passport Number:
Country of Issue:
Expiry Date:

C. WORK EXPERIENCE
Please provide two references, one from your present/most recent employer, if possible
1  
Company:
Address:
Employed From: To:
Time employed with company:
Job Description:
Name of Supervisor:
Include occupation/titles
Telephone: please include area code:
2  
Company:
Address:
Employed From: To:
Time employed with company:
Job Description:
Name of Supervisor:
Include occupation/titles
Telephone: (please include area code)

D. EDUCATIONAL BACKGROUND
HIGH SCHOOL:  
Address:
Dates Attended: From: To:
Length of Time:
Description of Studies:
HIGHER EDUCATION:  
- University / Vocational School / Technical School :
Address:
Dates Attended: From: To:
Length of Time:
Description of Studies:
- University / Vocational School / Technical School :
Address:
Dates Attended: From: To:
Length of Time:
Description of Studies:

E. FOREIGN EXPERIENCE
Please list as many experiences abroad as possible, beginning with the most recent. Please state the nature of your trip (work, study, pleasure,etc.) and include the length of time spent in those countries.
1  
Country:
Purpose of the Trip:
Dates: From: To:
Length of Time:
Notable Experiences or Comments:
2  
Country:
Purpose of the Trip:
Dates: From: To:
Length of Time:
Notable Experiences or Comments:
3  
Country:
Purpose of the Trip:
Dates: From: To:
Length of Time:
Notable Experiences or Comments:
4  
Country:
Purpose of the Trip:
Dates: From: To:
Length of Time:
Notable Experiences or Comments:
5  
Country:
Purpose of the Trip:
Dates: From: To:
Length of Time:
Notable Experiences or Comments:
6  
Country:
Purpose of the Trip:
Dates: From: To:
Length of Time:
Notable Experiences or Comments:

F. FINANCES:
Please indicate any financial obligations (note: Chilean wages are low compared to U.S. standards)
Principal Amount
Student Loans
Other Loans
Mortgage
Credit Cards
Alimony/Child Support
Other
Monthly Payments
Student Loans
Other Loans
Mortgage
Credit Cards
Alimony/Child Support
Other

G. LEGAL INFORMATION
Granting a visa requires a referral to the State police to check if the applicant has a criminal record.
Have you ever been convicted of an offense other than a traffic violation?
Yes No  
If yes, please explain:

H_ MILITARY SERVICE
Yes No
If yes please include a copy of your discharge.

I. LANGUAGE PROFICIENCY
1. What is your first language?
2. Rate your proficiency in other languages as follows:
(E) Excellent, completely fluent
(G) Good, able to perform professionally
(F) Fair, able to perform socially
(P) Poor, some knowledge of the language.
Rate your ability to:
Language Known 1:
Speak Read Write Understand
Language Known 2:
Speak Read Write Understand
Language Known 3:
Speak Read Write Understand
Language Known 4:
Speak Read Write Understand

J. EMERGENCY CONTACS
In case of emergency please provide two contacts:
Name:
Include relationship to you
Address:
zip code
Telephone (Home) ( please include area code)
Telephone (Work) ( please include area code)

K. PERSONAL STATEMENT

THE PERSONAL STATEMENT IS OF UTMOST IMPORTANCE AND CAN BE SENT BY MAIL.

This is an opportunity to express yourself freely to tell us who you are. Your personal statement can form the basis for dialogue in your telephone interview. Please use the following outline in preparing one or two pages to describe:

You and your personal relationships: Tell us a bit about your family and its influence on you, highlight experiences or relationships that you see as important in your development. How do you get along with people, upon first meeting them, in working with them, in social situations? Describe any leadership experiences you have had.

Describe any instance where you have associated with people from different cultures. How do you feel about living and working in another culture? How do you cope with difficult or stressful situations? Can you describe the level of physical comfort/amenities you feel you would need overseas?

You in work situations: Tell us in what situations you work best; which ones cause you difficulties? Relate any experiences when you had to be resourceful (finding material, equipment etc.,) to get the job done; times that you felt very creative in getting the job done; times that you had to be flexible. Describe your worst job experience and your best job experience; what made them good or bad?


PART 2

MEDICAL INFORMATION
1. What medical problems do you have at present? Describe in detail.
2. Our method requires a lot of standing, do you think you will have a problem with this?
YES NO
3. Smog is sometimes a problem in Santiago, do you think you will have a problem with this?
YES NO
4. HAVE YOU EVER HAD OR HAVE YOU NOW: (Please check to the left of each item)
For each question marked "YES" explain fully on the reverse of this page including DATES. Number each explanation. Use additional sheets if required.
YES/NO < CHECK EACH ITEM
Sinusitis
Fequent or severe headaches
Migraine
Bronchitis
Tuberculosis
Shortness of breath
Pain in the chest
Heart disease
Low or high blood pressure
Dizziness or fainting spells
Stomach/Gastrointestinal trouble
Allergies
Varicose veins
Arthritis or Rheumatism
Paralysis (incl. polio)
Joint or spine disorder
Recurrent back pain
Epilepsy or fits
Depression or excess worry
Nervous trouble of any sort
Mental or emotional illness
Physical disability
Asthma
Throat disorders
Please answer YES or NO to the following questions
5. Have you ever experienced difficulty in your work because of inability to perform certain motions or assume bodily positions? ( If yes, explain)
6. Have you ever been refused employment or had your employment terminated because of your health?
(If yes, state reason and give details)
7. Have you ever had a major operation?
(If yes, describe and give date, surgeon and hospital)
8. Have you ever been a patient (committed or voluntary) in a mental hospital?
(If yes specify when, where, why, and name of doctor and complete address of hospital or clinic)
9. Have you ever had any illness or injury other than those already noted?
(If yes, specify when , where and give details)
10. Are you having, or have you had a drug, narcotic, or drinking problem?
(If treatment was required, give name of doctor, date, agency and treatment)
11. Are you taking medication on a regular basis?
(Most medication is available in Santiago)
Name of Medication TAKEN FOR DOSAGE HOW OFTEN & HOW LONG
12. IMMUNIZATIONS
Immunizations recommended are Immune Globulin (IG) and Typhoid
I hereby certify that the statements made by me in this application are true, complete and correct to the best of my knowledge and belief. I understand that a false statement, misrepresentation or omission made on the medical form, application or other documents requested by The Sam Marsalli English Language Institute, may disqualify me from acceptance and any subsequent contract or may cause my dismissal .
 
Name/Signature
Date

The answers to the above questions will be treated with strict confidence.

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