SSSNY 16th Social Justice Education Program Application Form

(This will be kept confidential and only made available to the Selection Committee.)

1. Name (in English):

(in Shan or Burmese) :

Age

Sex
M or F

Ethnicity

Religion

Married/Single

You MUST attach

your recent photo
here
Photo must have been
taken less than one
year ago

Number & age of

children if any

2. Date of Birth:

...............................

3. Place of Birth:

Township.....

4. Contact Address:

...............................
...............................

5. Telephone :...
6. E-mail: .. Viber ID. wechat ID.............LINE ID............
7. Fathers Name: ........... Mothers Name: .....
Fathers Occupation: ...... Mothers Occupation:
(Note: Applicants may be asked to verbally clarify or verify information concerning family or organizational relationships.
The school reserves the right to undertake background checks on all applicants.)

8. Education:
Education

From

To

Name of Institution

Primary School
Secondary School
High School
University
Other courses (or)
Training attended
(include ALL trainings)

Certificate Obtained

Remark

9. Work or Volunteer Experience: Please include ANY work (including unpaid) that you have done.
Date

Job Title

Responsibility

. ... .
. ... ..
. ... ..
. ... .
. ... .
10. Language skill: List the languages you know and check ( ) your skill level.
Languages

Spoken
Poor Good Fluent

Reading
Poor Good Fluent

Poor

Written
Good Fluent

11. Why do you want to attend SSSNY Social Justice Education Program? What are you
interested in doing after you complete the course?

12. Other information you wish to provide:

13. Have you ever applied to SSSNY before? If yes, when? .

14. What kind of identification documents do you have?

Work permit/Temporary Passport (Myanmar) Myanmar ID
Thai ID card

Nothing

Passport (Myanmar)

Other (specify) .........

If you have a Myanmar passport, have you ever traveled on a visa to Thailand before?
Yes No
If Yes, what type of visa did you have and when did you travel to Thailand?
...
15. Where could you attend test and interview?
Chiang Mai

Piang Luang/ Kung Kyaw Fang

IDP Camp 1

Lashio

Mae Sai

Taunggyi

Other (specify) .........

Information provided to the SSSNY is confidential. By signing this document, I verify all
information to be accurate to the best of my knowledge. If the information provided is found to
be false, I understand my application may be rejected. I additionally understand that if I am
accepted, I will be responsible to repay the school for any visa processing and transportation
fees if I change my plan and decide to withdraw from the program.

....

Applicants Signature

Date of Application

Please return this application form to ONE of the following addresses by Feb 29, 2016
Postal address:

16th SJEP (SSSNY), P.O. Box 110, Phrasing Post Office, Chiang Mai 50205
OR

Email:

sjep@sssny.org

Tel:

082 761 2776

Please note: Applications MUST be supported by a letter of recommendation. Letters of recommendation must
also be submitted no later than April 29, 2016.

16. Recommendation Letter:

(This will be kept confidential and only made available to the Selection Committee.)

Please avoid general comments such as "He/she is weak in English" or "She/he is an obedient student." Try to be specific
about why you feel this person should be selected for the Social Justice Education Program. Recommendations may be
written in first language i.e. Shan or Burmese. You may attach a separate letter to this form.

RECOMMENDATION FOR for SSSNY 16th Program (2016)

Name of Applicant)
SECTION 1: To be completed by community or organisation leader/ representative.
1. Your name: ..:.
2. Name of organisation:

3. Position / Responsibility within organisation:

4. Contact address:
Phone:. E-mail:.
SECTION 2:
Please answer the following questions:
1. How long have you known the applicant?:
2. Please explain your relationship to applicant: ..
...
3. Please comment on why you support the applicant's selection for SSSNY:
....
....
4. Please describe the applicants
i) strengths ...............
....
ii) weaknesses ..

Information provided to the SSSNY is confidential. By signing this document, I verify all information to
be accurate to the best of my knowledge. If the information provided is found to be false, I understand
the applicant may be rejected.
..

Signature of recommender

Date

Please return this recommendation form to ONE of the following addresses by April 29, 2016.
Postal address:

16th SJEP (SSSNY), P.O. Box 110, Phrasing Post Office, Chiang Mai 50205

Email:

sjep@sssny.org

For further information: Tel:

+66 82 761 2776, +66 99 371 6302, +66 80 494 6033, +66 81 764 5501