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Other Relevant Experience
21. Briefly describe any relevant volunteer experience, community involvement, etc. Part 4: Health & Other Information Health & Medical Information 22. Do you have any physical, emotional, or psychological conditions that we should be aware of? Yes No If yes, please describe:
23. Do you have any dietary restrictions and/or allergies? Yes No If yes, please describe:
24. Do you have health and/or medical insurance? Yes No If yes, please indicate the following: Type of coverage: Provider: Policy Number: Other Information 25. How did you hear about this fellowship? 26. Do you have access to a computer and the internet? Yes No If yes, where? Home Work Other:
Part 5: References
Reference Contact Information Please list your two references below so that we may contact them.
27. First Reference Contact Information: Name: Title: Organization: Address: Country: Postal Code: Phone number: Fax number: Email address:
28. Second Reference Contact Information: Name: Title: Organization: Address: Country: Postal Code: Phone number: Fax number: Email address:
Part 6: Your Organization
Organization Purpose 29. In one sentence, please describe the overall purpose or goal of your organization:
Organization Size 30. Number of full-time employees: 31. Number of part-time employees: 32: Number of volunteers: 33: Number of employees directly under your supervision: 34. Name and title of your direct supervisor: Organization Budget 35. Overall budget of organization: 36. Where does your funding come from?
37. Does your organization have an endowment?
Organization Official Registration 38. Date officially formed: 39. Government or administrative body registered with: 40. Location of headquarters / main office:
Date: 2016-01-05; view: 812
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