Summer 2009 Capitol Hill Internship Application Form

DIRECTIONS: Please complete, print and sign the Summer 2009 Capitol Hill Internship Application Form available offline. All information provided is for the sole use of the office of the hosting US lawmaker.

Intern information

Full Name:
(First Middle Last)

Gender:

Date of birth:

(DD/MM/YEAR)

Polish passport #:

US visa #:

Correspondence address:

 Street: 
 Postal code:     city: 
 country:         

Permanent Residence address:

permanent address is the same as correspondence

 Street: 
 Postal code:    city: 
 country:        

Primary tel:

 

Secondary tel:

 

E-mail:

Emergency contact:

Name
Relationship
addres
tel: 
fax:
e-mail:

School Information

Public Private:

University name, year of attendance and major course study

University name:

year of attendance:

major course study:

University address and Faculty member contact details (tel. and e-mail)

University address

 street: 

Faculty member  name:

title:

contact details:

 postal code:   city: 
 country 
 tel:         e-mail: 

2007 intern placement fee:

 

 

Wire transfer details:

 

Receiving Bank Name:
Account owner:


Terms of Acceptance:

By signing this application, the internship participant agrees to the following terms:

US-EU Government Initiatives, its organizers and directors, shall be held harmless for any injury, loss, damage or delay resulting from any act or neglect of any person or company whose services are retained for the benefit of program participants, including but not limited to accommodation, transportation or meal providers. It is the expressed declaration of US-EU Government Initiatives that its organizers and directors will accept no responsibility for any unforeseen incident or "Act of God" that might occur on the part of any commercial carrier from the time the intern leaves country of his/her residence until his/her return home. Each intern must assume sole responsibility for his/her personal possessions and medical costs, whether for elective procedures or emergency care. A review of appropriate insurance coverage is highly recommended.

 

X _________________________________________________

               Intern signature (attesting to acceptance of the foregoing terms)


___________________________________________________

                         Intern full name (print)

Mail your completed application (address must appear in full, as below),
including proof of payment to:

Marek S. Podhorecki
Director

US-EU Government Relations
Żytnia 18 A

01-014 Warsaw Poland