APPLICATION NUMBER: _____

EDUCATION AS A VACCINE AGAINST AIDS INCORPORATED (EVA)

INTERSHIP PROGRAM

PROGRAM SESSION: ________PROGRAM AREA: ___________PROGRAM LOCATION: ________

BIOGRAPHICAL INFORMATION

___________________ _____________________ _________________

LAST NAME FIRST NAME MIDDLE NAME

______________________

PREFERED/ OTHER NAME

___________ ________ ___________________________

AGE SEX ETHINIC BACKGROUND

________________ _________________ ________________________

PLACE OF BIRTH PLACE OF ORIGIN RELIGIOUS PREFERENCE

_____________________________________ _________________

_____________________________________ PHONE NUMBER
PERMANENT ADDRESS _________________

_______________________________________ E-MAIL ADDRESS

_______________________________________ _________________

CURRENT ADDRESS PHONE NUMBER

EDUCATIONAL BACKGROUND

Please circle one:

SOPHMORE JUNIOR SENIOR GRADUATE

___________________________ ____________________________

NAME OF INSTITUTION MAJOR/ AREA OF CONCENTRATION

________________________________ ____________________________ ______________

EXPECTED/OBTAINED DEGREE EXPECTED/OBTAINED DATE GPA

WORK/VOLUNTEER EXPERIENCE

Please list all relevant work experience to the area of interest. Also attach a full resume/C.V.

DATES TITLE/POSTION HELD DESCRIPTION

__________ _____________________ ____________________________________

__________ _____________________ ____________________________________

__________ _____________________ ____________________________________

__________ _____________________ ____________________________________

GENERAL INFORMATION

v LIST ALL LANGUAGES OTHER THAN ENGLISH

__________________________________________________________

v LIST ANY FELLOWSHIPS/SCHOLARSHIPS RECEIVED

_______________________________________________________________

_______________________________________________________________

v LIST ANY HONORS/AWARDS RECEIVED

__________________________________________________________

__________________________________________________________

v LIST ANY RESEARCH EXPERIENCE/PUBLICATIONS

_______________________________________________________________

_______________________________________________________________

v LIST ANY EXTRACURRLICULAR/COMMUNITY SERVICE ACTIVITIES

_______________________________________________________________

_______________________________________________________________

SKILLS

Please circle all that applies:

Computer Communications Creative

Typing/Word Processing Advertising Theater

Data Entry Public Speaking Art (Drawing/Painting)

Web Page Design Other______________ Photography

Graphic Design Writing/ Journalism

Microsoft Excel Other____________

Microsoft Word

Microsoft Publisher

Adobe Photoshop

Adobe PageMaker

Power Point

SPSS

Other_____________

ESSAY/PERSONAL STATEMENT

Please answer the following question. All answers must be limited to two- three pages and 11-point font.

1. Which area of focus is you interested in and why?

2. Name 3 adjectives that best describe your personality and explain why. In what ways will these characteristics enhance the area of EVA you are applying for?

3. What is your opinion about open discussions regarding sex and sexual related topic in high/secondary schools?

4. What issues do you feel people living with HIV/AIDS (PLWHA) in African countries have to deal with and how will you address this issue?

5. Describe a valuable experience (internship, volunteer, etc.), that you believe makes you the best candidate for this program?

6. How do you intend on financing this program?

7. How will this program complement or enhance your future goals?