Last Name:
First Name:
Email:
Sex:
Male
Female
Date of Birth:
Month
January
February
March
April
May
June
July
August
September
October
November
December
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Day
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Place of Birth:
Nationality:
USA
Canada
United Kingdom
Ireland
Austria
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Barbuda
Argentina
Armenia
Australia
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Chile
China, Peoples Republic of
Colombia
Comoros
Congo, Democratic Republic of
Congo, Republic of
Costa Rica
Cote d Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea (North)
Korea (South)
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts & Nevis
Saint Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Taiwan
Timor-Leste
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
Passport Number:
Destination:
Chile
Peru
Ecuador
Costa Rica
Honduras
Uganda
Ghana
Malawi
Kenya
Cameroon
South Africa
Zambia
Tanzania
Nepal
India
Philippines
Project:
Arrival Date:
Month
January
February
March
April
May
June
July
August
September
October
November
December
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Day
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Year
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Departure Date:
Month
January
February
March
April
May
June
July
August
September
October
November
December
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Day
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Year
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Please describe your professional skills, training, language skills:
Please describe your educational background including certificates etc
What is your native language?
Do you speak another language?
Yes
No
Have you ever lived or traveled abroad? Please describe in detail:
Please tell us about your hobbies, interests, extra-curricular activites.
Which volunteer program are you interested in and why?
If given a preference which type of accommodation do you prefer:
homestay
local guesthouse
at the orphanage (not always applicable)
Do you have any special dietary requirements?
Do you have any allergies or medical conditions?
Please indicate your relevant skills and interest.
How did you hear about us? Please specify the keywords you used and what browser did you used.
Would you be willing to talk with
future A Broader View volunteers upon your return to share your experiences or
take part in other A Broader View activities and
programs?
Yes
No
Preferred method of communication:
Phone
Email
Both
Have you been convicted of a felony?
Yes
No
Within the past five (5) years have you been convicted of, or completed
a period of incarceration for, a misdemeanor which was not a first
conviction for drunkenness, simple assault, speeding, a minor traffic
violation, an affray, or disturbing the peace?
Yes
No
Please Note:
1. Conviction of a crime or a guilty plea to a criminal charge will not
necessarily disqualify an applicant. A Broader View will consider the
gravity of the offense, the time passed since conviction or plea and
the nature of the volunteer position sought.
2. An applicant with a sealed record on file with the commissioner of
probation may answer ‘no record’ with respect to an inquiry herein
relative to prior arrests, criminal court appearances or convictions.
In addition, any applicant may answer ‘no record’ with respect to any
inquiry relative to prior arrests, court appearances and adjudications
in all cases of delinquency or as a child in need of services that did
not result in a complaint transferred to the superior court for
criminal prosecution.
The volunteers have read and understand the Terms & Policy .
Please make a selection. YES I Understand
You can mail or fax your application or payment to us:
A Broader View Volunteers. P.O. Box 14. Wyncote, PA 19095
Tel: 215-782-1845 Fax: 215 887-0915