APPLICATION FORM
MEETING YOUTH 2005 – “TO BE IS TO INFLUENCE”
(PLEASE PRINT IN BLOCK LETTERS)
NAME:…………………………………………………………………………………..,,
DATE OF BIRTH: DAY………… MOUNTH……………………YEAR…………….
PLACE OF BIRTH:……………………………………………………………………….
COUNTRY:………………………………………………………………………………
STATE/ PROVINCE:…………………………………………………………………...
ADDRESS (NUMBER, STREET, CITY, STATE/PROVINCE, POSTAL CODE)
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HOME TELEPHONE NUMBER………………………………AREA CODE………
BUSINESS TELEPHONE NUMBER………………………….AREA CODE………
HOME OR BUSINESS FAX NUMBER………………………AREA CODE……….
E-MAIL ADDRESS:……………………………………………………………………
OCCUPATION:………………………………………………………………………….
ACADEMICAL CERTIFICATIONS:…………………………………………………
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SCHOOL WHERE YOU WORK OR ORGANIZATION WHERE YOU DEVELOP YOUR ACTIVITY:……………………………………………………
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ADDRESS: ……………………………………………………………………………
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INVOLVEMENT IN COMMUNITARY WORK: …………………………………
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HAVE YOU EVER ATTENDED ANY WORKSHOP IN PORTUGAL?
YES………………………………………………. NO…………………………………
IF YES, WHEN AND WHERE?......................................................................................
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WHEN DID YOU EMIGRATE? (IF APLLICABLE):……………………………….
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HAVE YOU EVER VISITED THE AZORES?
YES……… NO……… WHEN?.......................................................................................
REMARKS/CONSIDERATIONS YOU FIND USEFUL FOR YOUR APPLICATION:…………………………………………………………………………
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INFORMATION FROM THE CONSULATE OF PORTUGAL (OPTIONAL)
RECOMMENDATIONS FOR THE PARTICIPATION OF THE CANDIDATE
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I HEREBY DECLARE TO KNOW, AGREE AND COMPROMISE MYSELF TO FOLLOW THE TERMS AND CONDITIONS OF THE REGULATIONS OF THE MEETING YOUTH 2005 – “TO BE IS TO INFLUENCE”.
SIGNATURE:……………………………………………………………………………