Summer 2006 Congressional Internship Application Form

DIRECTIONS: Please complete, print and sign the Summer 2006 Congressional Internship Application Form
available offline.
Should you have any difficulty downloading the file or require further assistance, feel free to contact me.

Intern information

Full Name:
(First Middle Last)

Gender:

Date of birth:

(DD/MM/YEAR)

Polish passport #:

US visa #:

Correspondence address:

 Street: 
 Postal code:     city: 
 country:         

Permanent Residence address:

permanent address is the same as correspondence

 Street: 
 Postal code:    city: 
 country:        

Primary tel:

 

Secondary tel:

 

E-mail:

Emergency contact:

Name
Relationship
addres
tel: 
fax:
e-mail:

School Information

Public Private:

University name, year of attendance and major course study

University name:

year of attendance:

major course study:

University address and Faculty member contact details (tel. and e-mail)

University address

 street: 

Faculty member  name:

title:

contact details:

 postal code:   city: 
 country 
 tel:         e-mail: 

Method of payment:

Polish interns may pay for the internship program administration fee via banking wire transfers. The payment shall be made out to IKO, for the account #

Account nr:

Instytut Kszta³cenia Obcokrajowców S.C.
ING BANK ¦L”SKI 83 1050 1038 1000 0022 4790 3046

Terms of Acceptance

By signing this application, the internship participant agrees to the following terms:

The United States-Poland 2005 Parliamentary Summer Internship Program, its organizers and directors, shall be held harmless for any injury, loss, damage or delay resulting from any act or neglect of any person or company whose services are retained for the benefit of program participants, including but not limited to accommodation, transportation or meal providers. It is the expressed declaration of the United States-Poland 2005 Parliamentary Summer Internship Program that its organizers and directors will accept no responsibility for any unforeseen incident or "Act of God" that might occur on the part of any commercial carrier from the time the intern leaves country of his/her residence until his/her return home. Each intern must assume sole responsibility for his/her personal possessions and medical costs, whether for elective procedures or emergency care. A review of appropriate insurance coverage is highly recommended.

 

X _________________________________________________

                Intern signature (attesting to acceptance of the foregoing terms)


___________________________________________________

                        Intern full name (print)

Mail your completed application (address must appear in full, as below),
including proof of payment to:

Marek S. Podhorecki
Director

United States-Poland 2006 Parliamentary Summer Internship Program
c/o American Chamber of Commerce in Poland
Warsaw Financial Center
ul. Emilii Plater 53, 30th floor
Warsaw 00-113 POLAND