Legislative Drafting Program for South Africa
Internship Application Form

CLOSING DATE: 2 JULY 2004

Date submitted: __________________________________
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Please type application or print legibly in black ink:

PERSONAL INFORMATION
Last name____________________First name______________Middle____________________
Place of Birth: City______________________Country_________________________________
Date of Birth (dd/mm/yy)__________Citizenship____________Religion___________________
Sex: Male ? Female ? Marital Status: Single ? Married ?
Home address________________________________________________________________
____________________________________________________________________________
City_____________Country___________Phone #_____________Fax #__________________
E-mail address _______________________

LANGUAGES
Languages in which you are proficient other than English?______________________________
Have you traveled abroad before? If yes, give dates and locations _______________________
____________________________________________________________________________

EMPLOYMENT HISTORY
Number of years of full-time professional experience__________________________________
Present employer___________________________________Date employed_______________
Your position title_________________________Specialty______________________________
Office address________________________________________________________________
____________________________________________________________________________
City_______________________________Country____________________________________
Phone #_________________Fax #________________E-Mail address____________________

Describe the purpose and function of your organization and your responsibilities in it.

What professional skills do you want to learn in the United States? This information will be helpful in determining your placement. How would this professional development be relevant to you and your organization in your home country?

What skills and expertise do you wish to share with colleagues in an American organization working in your field?

PROFESSIONAL DEVELOPMENT AND CAREER ISSUES (Please use separate pages, if necessary)

What are your long-term goals?

BIOGRAPHICAL INFORMATION (Attach additional pages if necessary)

Describe any personal information, experiences or skills that would contribute to your success as an intern (both in the US and after you return home)

EDUCATION
Last institution attended_________________________________________________________
Dates of attendance: From___________to___________Degree received__________________
Specialization_________________________________________________________________
Other institutions attended & dates________________________________________________
Awards/Honors________________________________________________________________

PLACEMENT INFORMATION
The medical insurance that you will receive during your stay in the USA will not cover any pre-existing medical conditions. Do you have any health problems or physical disabilities that should be taken into account in your placement? ___________________________________________
Are you currently taking any medication? YES ??NO ? If yes, please indicate kind of medication and why____________________________________________________________
Dietary restrictions?____________________________________________________________
Do you smoke? YES ??NO ? If yes, can you confine the smoking? YES ??NO ?
Do you have objections to others smoking? YES ??NO ?
Do you object to host families having pets? YES ? NO ??
If yes: CATS? ??DOGS? ??ALL PETS ? ?
Do you have an international driving license? YES ? NO ?
Name/Address/Phone of contact person in case of emergency
____________________________________________________________________________
____________________________________________________________________________

FOREIGN TRAVEL OR RESIDENCE
Country______________Year of visit_________Reason_______________________________
Country______________Year of visit_________Reason_______________________________
Country______________Year of visit_________Reason_______________________________

Relatives in the United States? YES ? NO ??If yes, give name, address and relation to you_________________________________________________________________________
Hobbies and leisure time interests_________________________________________________

CURRICULUM VITAE
Please attach a copy of your curriculum vitae or, in a brief narrative, describe your background, education, practical experience and significant influences on your personal, educational and professional development.

REFERENCES
Please submit two letters of reference from professional colleagues

Please type or print and attach additional pages for any questions beyond the spaces provided on this form. All application materials should be returned to Prof CJ Botha, Department of Public Law, University of Pretoria, Pretoria 0002, Republic of South Africa. Telephone: (012) 420-2649. Fax: (012) 420-2991. E-mail: cjbotha@postino.up.ac.za.

I affirm that all information herein provided is true and accurate.

Signature___________________________________ Date___________________