AS&S Candidate Application Form: Nepal

...............CANDIDATE CONTACT INFORMATION.............





Suggestion:
For each question candidate should enter the exact information and some of the fields in this section may have to be re-entered, e.g. School Name. In order to facilitate the process, consider using a text editor to contain the repeated information. Then use copy and paste to enter the repeated information into the appropriate fields.

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* 1. Candidate's Full Name

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* 2. Gender

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* 3. Candidate's Marital Status. (State whether single, married or specify if other)

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* 4. Candidate's Age & Date of Birth(DOB)

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* 5. Candidate's Religion

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* 6. Candidate's Caste

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* 7. Candidate's Email Address

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* 8. Candidate's Membership in AS&S

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* 9. If Candidate is a current member of AS&S, provide their Entering Year.

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* 10. If Candidate is a current member of AS&S, what is the email Address assigned to you?
(Note: Your email will end with @asciencesociety.org)

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* 11. Candidate's Residential Address

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* 12. Candidate's Contact Address (If different from Residential address)

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* 13. Candidate's Phone Number (Land Line)

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* 14. Candidate's Cell/Mobile Phone Number

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* 15. Please provide Emergency Contact's Full Name

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* 16. Please provide an Emergency Contact Number(Land line & Moblie Phone Number)

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* 17. Candidate's Father/local Guardian's Name, Address, Email and Phone information

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* 18. Candidate's Grade Level/Rank/Class/Percentage of marks obtained in the current or last Exam/Assessment.

......................................CANDIDATE'S DEMOGRAPHIC INFORMATION.......................................

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* 19. Please provide the name of Region and Zone where you were Born

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* 20. Please provide name of the Region and Zone where your Mother was Born

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* 21. Please provide name of the Region and Zone where your Father was Born

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* 22. For How many years are you living in Nepal

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* 23. Candidate's Mother tongue/ Native language

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* 24. What is your Ethnicity

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* 25. Besides English, list other languages you know

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* 26. Provide your family's and/or Your Citizenship Card Number

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* 27. Current Educational Status

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* 28. Candidate's Type/Mode of Education

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* 29. Current Class/Standard if in High Secondary School(HSS) or below.

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* 30. What is the name of your School/College/University/Institute

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* 31. Enter your School/College/University/Institute address

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* 32. Please enter your current rank and/or Percentage of marks in your present or last exam/assessment

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* 33. What is your Present Family status (State whether APL (Above Poverty Line or Below Poverty Line)

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* 34. Are You or Your family members being coverd under any insurance scheme, please specify the Type of Insurance Scheme you are involved into Select all that apply.

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* 35. Your Household's total or gross Annual Income

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* 36. How many members are there in your Household (including yourself)

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* 37. How many Siblings do you have

......................CANDIDATE'S ACADEMIC INFORMATION..........................

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* 38. Are your Siblings Educated if yes please specify at which Level

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* 39. Would you be the FIRST in your family to finish (Tick mark all that apply)

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* 40. What Extracurricular activities are you interested in?

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* 41. What are your two highest Career Choices?

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* 42. Indicate your Proficiency/Preference/Comfort Level (Mention your levels as High, Average or Low)

  Proficiency Level Preference Level Comfort Level
Zoology
Social Science
Physics
Mathematics
Earth Science
Chemistry
Botany
Biological & Life Sciences

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* 43. Choice for your area of research:
In order to best match you with a mentor, please indicate your First (1st), Second (2nd), Third (3rd), Fourth (4th) and Fifth (5th) preferences.

  Highest - First Second Third Fourth Lowest - Fifth
Agriculture & Natural Resources
Astronomy
Architecture & Environmental Design
Atmospheric Science
Computer Science
Engineering
Bio/Informatics
Biotechnology
Ecological Science
Environmental Science
Medical Sciences
Epidemiology
Statistics
Robotics
Anthropology
Psychology
Science Reporting/ Writing
Science Advocacy
Legal Science (Patent Law, etc)
Forensic Science
Communications
Linguistic Sciences
Library Science
Nutritional Science
Health Professions
Actuarial Science
Social Sciences
Botanical Sciences
Animal Husbandry
Veterinary Medicine
Complementary Medicine (Naturopathy, Chiropractic, Herbalism, Traditional Chinese Medicine, Unani, Ayurveda, Medicine, Yoga, Biofeedback, Hypnosis, Homeopathy, Acupuncture, Nutritional based therapies, etc.)

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* 44. What are your long term career goals?

..............CANDIDATE ADMINISTRATIVE INFORMATION.................

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* 45. What is the name of the person who recommended you for membership?

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* 46. What Institute or organization was the person recommending from

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* 47. What is the email of the person who recommended you?

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* 48. In what year were you recommended (as yyyy)?

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* 49. Are you or any member of your household (0-64) years of age covered by Medicaid, Child Health Plus, Family Health Plus or Private Medical Insurance?

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* 50. If You are NOT covered by insurance, do You want to be contacted with information about public health insurance programs?

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* 51. Are You interested in participating in volunteer community service this summer (For male applicants 18 and over, registered with Selective Service)

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* 52. Enter you Registration Number if You have and/or given one

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* 53. Enter Registration Date as Day/month/Year, If You have or had been given One in the Past

Date
CERTIFICATION OF ACCURACY
I, the undersigned, am of legal adult age and certify that all information on this form is true and correct to the best of my knowledge and understanding. I understand that my statements are subject to verification. I further understand that any false statements may subject me to criminal prosecution under Indian Penal Code(IPC).
I agree and accept that I will abide by all applicable rules and regulations of this program.
If you agree to all of the above, type your full name, state that you are the applicant, or the legal adult on behalf of the applicant, who completed this form.
Type one or the other of the following responses shown below:
I, (your name), am the applicant of legal adult age who has completed this form and have read, understood and agree to all the above.
I, (your name), am the adult of legal adult age, who has completed this form on behalf of the applicant and have read, understood and agree to all the above.

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* 54. Enter your response as indicated above

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* 55. Date Application Completed

Date
© MMX by Association of Science and Society and Harlem Children Society.
All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of Association of Science and Society and Harlem Children Society.

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