ICE :: Information Request

I.C.E. - Placement

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Personal Information First Name
Last Name:
Address:
P.O. / Apt
City
State
Zip code
Country
Home Phone
Email
Date of Birth
[ day - month - year ] format (25 - 10 - 90)

Interest Which program(s) are you interested in?
First Choice
Second Choice
Internship Location

Academic Details Term of Enrolment
Spring 2010
Summer / Fall 2010
Winter 2010
2011
Last School Enrolled in
GPA
Year in School

Other details How did you know about our site?
Internet search
GoAbroad.com
Magazine
Friend
Interim Programs
Study Abroad Fair
Other
Please state
My main interests are: (check all that apply)
Environmental conservation
Social advocacy
Teaching
Religious studies
Language immersion classes
Workshops on environment & culture
Marine biology

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