APPLICATION FORM Personal Details Surname:                                First/Christian Name:                                    DOB: Address: Home Phone:                      Mobile Phone:                                     Email: Country of Birth:                          Citizenship: Marital Status: married/ single/ widowed / separated/ divorced/ de facto partner Family Details Please list accompanying family members/partner Family name                         First name               Relationship                   DOB _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________  Alternative Contacts – Next of Kin Name: ________________________ Phone number: _____________________ Exchange Location Preferences Ranking 1 most preferred Location __ Australia __ Canada__ New Zealand __ Singapore __ England, UK__ Northern Ireland, UK __ Scotland, UK__ Wales, UK__ USA. Employer Details Agency/school/institute/organisation name: Address: Phone number:                                FAX number:                             Email: Name of your supervisor/manager: Name of Chief Executive Officer: Professional Profile Please state qualifications and list O&M work experience (including dates and places of employment). To assist your exchangee and host employer please describe your professional life and work environment (including your client demographics, number of other O&M Specialists, if you have supervising experience, variety of work experiences eg kids, multiple disabilities, elderly and any additional skills, languages you possess). Please ask your employer if there are any additional qualifications or skills they require the exchangee to possess(List in the space below). Although SWITCH! does not endorse the exchange of participants private cars some employers provide vehicles. Yes__ No__ Will your employer provide a vehicle for use at work? Yes__ No__ Will your employer be providing a vehicle for private use? Make of Vehicle ___________________  Year__________ Yes__ No__ Is this Vehicle fully insured? Home Location How far is your home location from: workplace ____ urban centre___? Type of location: City suburb__ Central City__ Country town__ Rural__? How do you travel to the workplace_______? Is there public transport__? In the space provided please give a detailed description of your home locality Accommodation Details You must agree to either exchange your own current accommodation or make suitable arrangements i.e. fully furnished rental property for one year. This is a private arrangement between exchange participants. Additional details may be provided once an exchange proposal has been made. The accommodation I provide would accommodate ____adults ___children. I require a minimum of __bedrooms and __beds. Type of accommodation offered for exchange? _______ (Detached house__Flat/apartment__Townhouse__Other: ________) Owned___ Rented___Current market value___________? Please give a  description of your home (including rooms, appliances, climate control – fuel type and extent of heating or air conditioning): Please attach: 1) an A4 montage of photos of your home and work. 2) written reference from your employer. ------------------------------------------------------------------------------------------- SIGNED AGREEMENT I have read and noted the FAQ and information about the exchange programme for Orientation and Mobility Specialists. I have completed the form accurately and will work for the full term of the exchange in the host country under their terms and conditions. I have enclosed a money/postal order for A$50 and three copies of this form. My employer has agreed to retain me as an employee and host an exchangee. I understand there are risks involved in participating on an exchange and I will not hold the founder, office bearers or members of SWITCH! The Orientation and Mobility Instructors Exchange Programme liable. Signature: ________________________ Date: __________________ Privacy Notice – The information in this application is given voluntarily for the purpose of participation in the exchange programme. It may be provided to exchange counterparts and host employers. The information will be stored securely and can be updated by writing to SWITCH! Po Box 2024  ROSSMOYNE WA 6148 AUSTRALIA.