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A. BACKGROUND
INFORMATION
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| Name:
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| Title: |
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| Address |
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| City:
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| Province/State:
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| Postal/Zip Code:
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| Country:
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| Work Phone Number:
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| home Phone Number:
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| Fax Number:
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| Pager:
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| e-mail:
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| URL/Website:
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| Marital Status:
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| Date
of Birth:
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| Sex: |
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| Highest Degree
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| Major: |
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| School: |
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| Emergency
Contact Person: |
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B. SKILLS, TRAINING AND MOTIVATION
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1. What
health/IT skills do you posses?
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2. Tell us about any
IT or health training you have done in your community, either technical
or otherwise:
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3a. Do you have any foreign
language skills?
Yes
No
3b. If yes, kindly list the foreign language skills you have:
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4.
Have you traveled and/or worked in an African country?
Yes
No
4a. If yes, tell us
about your travel/work experiences in African countries:
5.
How long are you willing to volunteer?
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6.
Kindly state your interest in becoming an AAMCT IT/HealthCORPS Volunteer
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7. What
conveniences/comforts do you think you will miss most? Please explain
why:
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8.
List any physical or
psychological conditions, including major illnesses, a) for which you
have received treatment within the last five years [explain on a
separate sheet of paper]; and, b) that we should know about, even if you
have not received professional attention:
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9. Submit a brief
autobiographical sketch that includes references to your previous
travel, group work, and personal experiences, and ideas that you have
that might support your candidacy.
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Interested persons
must submit their application to AAMCT as soon as possible, since plane
tickets for the program must be reserved well in advance.
I,
hereby certify that I have complied with the rules and regulations
governing AAMCT IT & HealthCORPS Volunteer Program
Payment of Fees:
Applicants must pay a non-refundable application processing fee of
US$50.00 All fees should be made payable to GhaCLAD. All payments
[check or money order] should be sent to the GhaCLAD postal address
[below].
GhaCLAD
P. O. Box 6749
Chicago, Illinois 60680-6749
Telephone: (312) 804-1909
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