Анкета для Участия Work&Travel USA | www.gepkaz.com | program@gepkaz.com

Work and Travel 2022

Регистрация Участника Пожалуйста, заполните все поля на английском
Personal information
Last Name(as in passport)*
First Name (as in passport)*
Date of Birth *

DayMonthYear
Дата рождения
Age| Возраст
Возраст
Email*
example@example.com
Skype*
Скайп адрес
Phone Number*

Area CodePhone Number
City of Birth*
Город Рождения
Citizenship*
Гражданство
Marital status| Семейное положение*

Женат/замужемНе женатгражданский браквдовец/вдоваOther
Постоянный Адрес
Address*

street

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Postal Code
Adress if different from aboe

Continue registration
Full Name as in passport

First NameFather's Name/OtchestvoLast Name
International Passport number *
Номер паспорта
City of passport issuance
Country of passport issuance
Int'l Passport issuance date

DayMonthYear
Date
Int'l Passport Expiry Date

DayMonthYear
Date
Have you ever lost your international passport? If yes, please indicate lost passport number and issuing country.
Education Information
University Name:*
Department/Faculty*
специальность и курс
University entry year*
B каком году поступили на учебу
University completion year*
в каком году заканчиваете или закочили учебу
Your English Level*

Fluent/свободное владениеAdvanced/Продвинутыйintermediate/СреднииElementary/Базовый
Travel Information
Desired employment start date
Desired arrival date to the US
Desired arrival airport
How long are you planning to stay in the US?
Desired return date to country of residence ?
Any siblings participating in the WT program this year? If yes, indicate Full Name of the sibling
Any chronic diseases preventing from program participation?
Any arrests, convictions or imprisonments?
Family Information
Mother's Full Name and Home address:*

Name

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mother's Place of Work
Mobile number of mother*

Area CodePhone Number
Father's's Full Name and Home address:*

Name

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Father's Place of Work*
Mobile number of father*

Area CodePhone Number
Brother and sisters names if any*
имя и номер телефона друга или подруги
Mobile number of siblings*

Area CodePhone Number
Your Best friend's name and mobile phone with country code*
имя и номер телефона друга или подруги

Work and Travel 2022

Personal information

Постоянный Адрес

Education Information

Travel Information

Family Information

Questionnaire

References

Additional Information