OOIIEE AAPPPPLLIICCAATTIIOONN FFOORR IINNTTEERRNNSSHHIIPP

APPLICATION FORM

(please type or write in block capitals in BLACK ink)

1. Surname (1) Forenames

.......................................................................................................................................................................................... 2. Full current address for correspondence

.......................................................................................................................................................................................... Telephone Fax Email

.......................................................................................................................................................................................... 3. Date and place of birth ....................................................................................................................................................

4. Sex { male { female 5. Present nationality (if dual, state both)

.......................................................................................................................................................................................... 6. KNOWLEDGE OF LANGUAGES Number the boxes as follows: 1 Excellent, 2 Good, 3 Basic working knowledge.

English French Spanish Other (s) (please specify)

7. EDUCATION (attach photocopies of certificates) A. Higher education (Undergraduate/graduate Level)

Name and address of establishment Years of study Degree or diploma obtained; state class. State (city, country) from to (2) official duration of course and main subjects

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........................................................... .............................. ............................... ............................................................ B. Postgraduate education

Name and address of establishment Years of study Qualification obtained (city, country) from to (2)

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(1) IMPORTANT: Your application will be registered under this name. Please use it in all correspondence. Any other name (e.g. maiden name) appearing on diplomas or certificates accompanying this application should be given here:

(2) Date of award of diploma etc. (month, year).

Office international des pizooties 12, rue de Prony 75017 Paris France Tel.: 33 (0)1 44 15 18 88 Fax: 33 (0)1 42 67 09 87 www.oie.int oie@oie.int

9. Published works: .......................................................................................................................................................................................... .......................................................................................................................................................................................... 10. Have you any dependants? { YES { NO If so, please give the following details:

Name Date of birth Relationship Name Date of birth Relation ship

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11. Previous employment and in-service training/internsyhip periods

Employer from To Nature of work Net monthly salary

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12. References: Please give the names and addresses of three persons to whom you are not related and who are able to give a

character reference and who know your qualifications.

Full name Full address (Telephone number if known) Occupation

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13. Please provide on two separate sheets evidence of endorsement (OIE Delegate, Reference Laboratory or Collaborating

Centre) and sponsorship. 14. Requested internship: Tat OIE Headquarters Tat an OIE Regional Representation (please state which one) 15. Using a separate sheet, please explain briefly (about 100 words) your reasons for applying for an internship at the OIE. Copies of graduation diplomas and other certificates must be attached to this form, which is to be returned, duly completed and signed, to the following address:

Head, Administrative and Financial Department OFFICE INTERNATIONAL DES EPIZOOTIES

12 rue de Prony 75017 Paris France fax: 33 (01) 42 67 09 87 administrative.dept@oie.int

I, the undersigned, declare that the information provided above is, to my knowledge, true and complete. I realise that any false statement or omission, even if unintended on my part, may lead to the cancellation of my application. ............................................................... .................................................................... (Date) (Signature)