Student Intern - Application Form

U.S.
MISSION VIETNAM
APPLICATION FOR FOREIGN NATIONAL
STUDENT INTERN PROGRAM
(AMERICAN CENTER)
1.
Position No./ Title:______________________________________________________________________
2.
FULL NAME:_________________________________________________________________________
LAST (SURNAME)
FIRST
MIDDLE
3.
PRESENT ADDRESS AND TELEPHONE NUMBER (E-Mail, if available):
Cell phone No.:

4.
Do you have any relatives that work for the Embassy/Consulate: If yes, please list name, department
where they work and how long they have been employed?
5.
CURRENT CITIZENSHIP:______________________________________________________________
6.
U.S. CITIZENSHIP: Do you have any claim to U.S. citizenship? YES_________NO_______
7.
UNIVERSITY/SCHOOL/EDUCATION INSTITUTION:
For each institution you have attended, provide the following information in the space below. Begin with
your present school and work backwards. Use continuation sheets as necessary.
Name and full address of current institution:
Name, title and telephone number of instructor:
Date you started University (Month/Year) ______________

Diploma/Degree/Certificate:_________________________
Date you expect to receive your college/university degree ____________ Major Field of Study:_________
8.
FAMILIARITY WITH AMERICAN CENTER

Have you ever been to the American Center?
Yes
No
If yes, what impresses you most? What do you think we can do better? (2 sentences)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9.
LANGUAGES: (Identify the language and indicate extent of your competence for each:
5 = fluent;
3 = good;
1 = fair;
0 = not at all)
LANGUAGE
SPEAK
READ
WRITE
UNDERSTAND
English
10. SPECIAL QUALIFICATIONS AND SKILLS:

List any special skills you possess and equipment you can use, certifications, licenses obtained, etc.
11. TRAINING RECEIVED:

List training received in areas applicable to the internship position in which you are applying.
12. VOLUNTEER, EMPLOYMENT OR EXPERIENCE (If applicable): Begin with your most recent
position and work backwards. (Use additional pages if necessary).
A. NAME AND FULL ADDRESS OF EMPLOYER:__________________________________________
__________________________________________________________________________________
B. DATES WORKED (month/day/year): FROM________________TO__________________________
C. TITLE OF POSITION:________________________________________________________________
D. NAME, TITLE AND TELEPHONE NUMBER OF IMMEDIATE SUPERVISOR:
__________________________________________________________________________________
E. DESCRIPTION OF WORK (Describe specific duties, responsibilities, and accomplishments):
F. NUMBER OF HOURS WORKED PER WEEK:_____NUMBER OF EMPLOYEES YOU

SUPERVISED___
13. HAVE YOU EVER WORKED FOR THE U.S. GOVERNMENT OR BEEN AN INTERN AT THE
AMERICAN CENTER?
YES___NO__
HAVE YOU EVER BEEN DISMISSED OR FORCED TO RESIGN FROM A POSITION? YES___NO__
PLEASE EXPLAIN:
14. COMPUTER SKILLS

How do you rate your computer skills (please circle):
5 = excellent;
3 = good;
1 = fair;
0 = none
List computer programs in which you have experience.
15. REFERENCES: List three persons not related to you by blood or marriage who are qualified to supply
definite information regarding your character and suitability for employment under the program. Do NOT
include former employers (i.e., supervisors).
NAME
MAILING ADDRESS
TELEPHONE
NUMBER
OCCUPATION
1.
2.
3.
16. YOU MUST SIGN THIS APPLICATION. Read the following carefully before you sign.
I understand that any information I give may be investigated and that a false statement may be grounds for
non- consideration or dismissal of my participation in the Intern Program, if I am selected.
I understand that, if I am provisionally selected, an Embassy-required security certification is a prerequisite.
I consent to the release of information about my ability and fitness for the Intern Program by employers,
schools, law enforcement agencies and other individuals and organizations to Embassy-authorized
investigators and personnel.
I certify that, to the best of my knowledge, all of my statements are true, complete, and made in good faith.
__________________________________
________________________________
Signature
Date
YOU MUST INCLUDE:

A copy of your identification card.

A copy of your school identification card.
A copy of your most recent school transcript.
CONTINUATION SHEET: ADDITIONAL INFORMATION (If applicable)

*************************************************************************************
VOLUNTEER, EMPLOYMENT OR EXPERIENCE (If applicable): Begin with your most recent position and
work backwards. Duplicate continuation sheets as needed.
A. NAME AND FULL ADDRESS OF EMPLOYER:_____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
B. DATES WORKED (month/day/year): STARTING FROM_________________TO_________________
C. TITLE OF YOUR POSITION:_____________________________________________________________
D. SALARY OR EARNINGS (Indicate if per week, month, year, etc.):
INITIAL SALARY:_____________per__________FINAL:_____________per___________________
E. NAME, TITLE, AND TELEPHONE NUMBER OF IMMEDIATE SUPERVISOR:
______________________________________________________________________________________
F. DESCRIPTION OF WORK (Describe specific duties, responsibilities and accomplishments):
G. NUMBER OF HOURS WORKED PER WEEK:____NUMBER OF EMPLOYEES YOU
SUPERVISED______
H. REASON FOR LEAVING____________________________________________________________
CONTINUATION SHEET: ADDITIONAL INFORMATION (If applicable)

*************************************************************************************
UNIVERSITY/SCHOLL/EDUATIONAL INSTITUTTION:
For each institution you have attended, provide the following information in the space below. Begin with your
present school and work backwards. Duplicate continuation sheets as necessary.
Name and full address of current institution:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Name, title and telephone number of instructor:
_____________________________________________________________________________________________
Dates Attended (Month/ Year)____________________Diploma/Degree/Certificate:__________________________
Date received:
______________________________Major Field of Study:_______________________________
Print Name (Last, First, MI)
ID Number (s chng minh th)
______________________________
______________________________
Statement of Interest
Write a brief Statement of Interest that describes why you seek an internship with the U.S.
Embassy Hanoi. Explain how the academic courses you have taken, and other personal
experiences you have had, relate to the Intern Program. Describe any public speaking or MCing
experience you have and tell us how familiar you are with the American Centers programs and
services.
UNITED STATES DEPARTMENT OF STATE

GRATUITOUS SERVICE AGREEMENT
Title 5 Section 3111 of the United State Code authorizes federal agencies to establish programs
designed to provide educationally related work assignments for students on a nonpayment basis.
You will be hired under such a program. According to the law, we may only accept your
gratuitous service if the service: (1) is performed by a student, with permission of the institution
at which the student is enrolled; (2) is uncompensated; and (3) will not displace any employee.
As a student participating under this program you will not be considered to be a federal
employee for any purposes other than injury compensation or laws related to the Tort Claims
Act. Your service is not creditable for leave accrual or any other employee benefits.
This arrangement is subject to termination at any time at the discretion of the Mission. Please
sign below acknowledging that you understand the terms under which you will be hired.
I understand the terms under which I am being hired, including, without limitation, that I will not
be compensated for the services that I provide.
__________________________________
______________________________
Signature of Intern
Date
________________________________
Full name of Intern

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U.S.

Position No./ Title:______________________________________________________________________

PRESENT ADDRESS AND TELEPHONE NUMBER (E-Mail, if available):

Cell phone No.:

U.S. CITIZENSHIP: Do you have any claim to U.S. citizenship? YES_________NO_______

Name, title and telephone number of instructor:

Date you started University (Month/Year) ______________

FAMILIARITY WITH AMERICAN CENTER

10. SPECIAL QUALIFICATIONS AND SKILLS:

11. TRAINING RECEIVED:

F. NUMBER OF HOURS WORKED PER WEEK:_____NUMBER OF EMPLOYEES YOU

14. COMPUTER SKILLS

List computer programs in which you have experience.

YOU MUST INCLUDE:

A copy of your identification card.

CONTINUATION SHEET: ADDITIONAL INFORMATION (If applicable)

CONTINUATION SHEET: ADDITIONAL INFORMATION (If applicable)

______________________________Major Field of Study:_______________________________

Print Name (Last, First, MI)

ID Number (s chng minh th)

UNITED STATES DEPARTMENT OF STATE

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U.S. CITIZENSHIP: Do you have any claim to U.S. citizenship? YES___NO_

Major Field of Study:_