Project MARC

2008 Volunteer Application Form

By submitting this questionnaire you certify that the information provided is true and correct (while being submitted in the understanding that it will be kept strictly confidential and used only for the purpose of making crew& team selections or assignments for Project MARC).

I - PERSONAL DATA

(1) Name:

(2) Home address:

(3) Telephone Numbers

(3.1) Tel. Home:

(3.2) Tel. Work:

(4) Fax #:

(5) E-mail address:

(6) Date of Birth:

(7) Nationality:

(8) Marital status:

(9) Person to be informed if anything were to happen to you (provide name, tel # and address)

(10) Personal character reference (provide name, telephone #, e-mail and address)

II - HEALTH STATUS

(1) How would you describe your own health?

(2) Are you aware of any pre-existing medical problems that could:

(2.1) - hinder your ability to carry out your specific project MARC tasks; (YES/NO)

(2.2) - affect your performance of general crew tasks on a small sailing vessel in the tropics; (YES/NO)

(2.3) - force you to seek medical help from other team members; (YES/NO)

(3) Do you take any prescription drugs? (YES/NO)

(4) Do you wear glasses or contacts? (YES/NO)

(5) Do you drink alcohol or kava? (YES/NO)

(5.1) IF YES; are you willing and able to restrict alcohol and/or kava usage to the weekends (and then only in moderation)?

(6) Do you smoke? (YES/NO)

(6.1) IF YES, are you able to live in a smoke-free environment?

(7) Are you addicted to any drug? (YES/NO)

(8) Do you have any particular fears or phobias? (YES/NO)

(8.1) IF YES, please specify

(9) Do you have any known allergies? (YES/NO)

(10) Do you get seasick easily? (YES/NO)

(10.1) IF YES, what medication works for you?

III - PROFESSIONAL TRAINING & EXPERIENCE

(1) List all your relevant medical, educational and/or technical diplomas, licenses and certificates (together with granting institutions and year obtained):

(2) List your professional experience (include year, employer and location):

(3) List previous experience with volunteer work (include year, organization and location):

(4) Provide the names, email addresses and telephone numbers of two teachers and/or supervisors who know your work well and are willing to provide professional reference information:

IV - PROJECT-RELATED AVAILABILITY & SKILLS

(1) Between July 1st and October 15th, 2008 you can be available during the following time period(s):

(2) You would be available to participate for 4 weeks / 8 weeks / longer than 8 weeks (specify):

(3) You are willing / unwilling to share a cabin with a compatible team mate? (specify):

(4) Your emergency first-aid skills (including CPR) are up-to-date / need a refresher course (specify):

(5) In your area of professional expertise you are willing / unwilling to apply for a Vanuatu license (specify):

(6) Describe any previous sailing or boating experience:

(7) Any experience with the following equipment, tasks or skills? Insert from the following: - Watchstanding - Anchoring - Sail Trim - Ropes and Knots - Chart Plotting- GPS - Radios - Computers - Cooking - Electronics Repair - Diesel EngineRepair - Outboard Engines - Carpentry - Welding - Scuba - Swimming (open water)

(8) Other relevant skills?

V - GENERAL INFORMATION

(1) Which foods do you strongly like or dislike?

(2) What music do you really like or dislike?

(3) What are your main interests / hobbies?

(4) Any outstanding or pending judgements against you (in any jurisdiction)?