1. Personal Information

Name:

Date:

Year of university graduation or expected graduation:

Citizenship

Passport No:

Country of Residence:

Address:

Telephone #/WhatsApp:

Email:

Skype ID:

2. Internship Details

How did you hear about FCAB?

What are your areas of interest?
HealthSanitationEducationAgronomics/LivelihoodOther

What are your personal expectations during the internship?

Do you have any program or professional deliverables or desired outcome?
If so, what are these? By when?

How will you fund your internship?
Internship Type:
Academic InternshipFCAB InternshipVoluntary Work for ProfessionalsPlacement as a Research Fellow (e.g., Fulbright)

Please specify the internship placement you are applying for, or your proposed study:


Reasons for applying for this placement:
What positive impact will you bring to the community?
How will you contribute to FCAB's work?

3. Personal/Professional Background

What is your academic major?
Have you taken any coursework that may be relevant to FCAB?
Any relevant field work or experience:

a) Skills and Experience

b) Knowledge of Bangla

Knowledge of Bangla is useful, though not necessarily critical.

Do you have any knowledge of Bangla?
YesNo

If yes, please state your level of proficiency:
Speaking:
A = FluentB = AdvancedC = IntermediateD = Basic
Listening:
A = FluentB = AdvancedC = IntermediateD = Basic
Reading:
A = FluentB = AdvancedC = IntermediateD = Basic
Writing:
A = FluentB = AdvancedC = IntermediateD = Basic

c) What concerns or questions do you have about living and working in Bangladesh?

Internship/volunteer placements involve working and living in rural Bangladesh, where facilities
including access to power, hot water, internet, heat or air conditioning, etc. are limited and it may
be hot, rainy and humid. Interns will be expected in most cases to share accommodations and eat
locally available food. They will be expected to dress and behave in a locally culturally appropriate
and respectful manner and be mindful of their personal security at all times.

If you have any medical or other conditions that might affect your ability to spend time in the field
during your internship placement, please describe these below:

Do you have any dietary restrictions?
YesNo
If so, please state them:

d) Medical Information

Do you have any allergies?
YesNo
If so, what kind? (Food, drug, etc.)

Are there any medications that you may be on during your internship or medical
conditions that we should be aware of:

Emergency Contact:

Name:
Telephone Number:
Email:
Relation:

If you are placed in an FCAB internship you must attest that you are medically sound to travel and
work in Bangladesh and that you are aware of and will have met the necessary medical
precautions, including vaccines, and will bring any required medications, etc. You may get an idea
of health precautions at:
https://wwwnc.cdc.gov/travel/destinations/traveler/none/bangladesh

All successful applicants are responsible for meeting all necessary travel authorization
requirements to travel to and intern in Bangladesh. Please check with the Embassy of Bangladesh
in Washington DC at www.bdembassyusa.org. They should also seek out travel warning
information from their respective relevant government agency.

FCAB bears no legal, financial or other liability for any accidents, violations of local or
international law or other incidents suffered or perpetrated by FCAB interns during their FCAB
internships or stay in Bangladesh. It is the responsibility of each intern to be aware of and comply
with all local laws and to carry the necessary travel, health and liability insurance during their stay
in Bangladesh. They must exercise caution and abide by customs to ensure their personal security.

FCAB interns are expected to bear all costs and expenses related to their internships and stay in
Bangladesh. FCAB may help them find lodging, travel and other logistical support but it is not
obligated to do so. Interns must fund their own costs and a portion of the FCAB operations costs
necessary to support their internships such as the cost of translators, program support, etc.

Interns may not take pictures of FCAB community beneficiaries/partners/employees, etc. without
first seeking their permission nor use them for commercial or personal purposes without informing
FCAB and compensating the subjects as appropriate.

Any and all materials created out of this internship shall belong to FCAB and no data or materials
created may be used or shared with the public or otherwise published or used commercially
without explicit permission to protect the privacy of our beneficiaries and for our organizational
integrity.

Interns may not disseminate any data, particularly beneficiary health or demographic data,
program information or other proprietary information gained from their access to FCAB
document or materials, field operations, FCAB database, etc. without seeking and receiving
written permission for any such use or dissemination.

Interns will share with FCAB any publications, reports or pictures/materials resulting from their internships which FCAB may, with intern's permission and knowledge, use and disseminate as appropriate such as through its website.

*All accepted interns must provide evidence of health insurance during orientation

4. Personal Statement

5. References

Students should provide contact details of two academic referees.
Volunteers/Professionals should provide contact details of professional and/or academic referees
(as relevant) and may additionally be required to submit a letter of recommendation from one of
the referees.

Please digitally sign this form by typing your full legal name in the box below.

By signing, you certify that the information contained in this form is true and correct to the best of your knowledge.