Student Intern Program Application Form 654321

U.S.
MISSION PHNOM PENH

APPLICATION FOR FOREIGN NATIONAL
STUDENT INTERN PROGRAM
1. Position No. /Title:

College Student

2. Do you have certification letter from your education institution? Yes No
Please list your proposed start and end dates of the Internship Program:
From (mm/dd/yyyy): December/01/2020 To (mm/dd/yyyy): May/30/2021
3. How many hours per week are you able to participate in the FNSIP? Please indicate hours per week. 42h/week
4. Last Name (Surname): Lyheng First Name: Kry
5. Present Address: PhnomPenh
6. Telephone number: 069973161 Email address: [email protected]
7. How did you learn about this program?
Job Advertisements Employee
Relative University/School
Other (Please Specify):
8. Do you have any relatives that work for the U.S. Embassy Government? Yes No
If yes, provide the details below: department where they work and how long they have been employed?
Name Relationship Agency, Position

9. Are you a citizen or legal permanent resident of the country where this U.S. mission is located?
(If you answered “no”, you are not eligible to participate in the FNSIP.) Yes No
10. University/school/education institution:

For each institution you have attended, provide the following information in the space below. Begin with your present school and
work backwards. Use continuation sheets as necessary.
10a. Name of school: Institute of Foreign Languages
Address: Russian Federation Blvd. Phnom Penh

Expected Date of Graduation
Date Attended (Month/Year): October/2017 October/2021
(Month/Year):
Diploma/Degree/Certificate: Bacholar Degree Major Field of Study: Professional Communication
Instructor’s name and contact information:
Name: Title:
Telephone number:
10b. Name of school: Cheasim Samkaky

Address: Street 271, Phnom Penh
Expected Date of Graduation
Date Attended (Month/Year): 2015 2017
(Month/Year):
Diploma/Degree/Certificate: Diploma Major Field of Study: Social Science
Instructor’s name and contact information:
Name: Title:
Telephone number:
11. Languages: (Identify the language and indicate extent of your competence for each)
5 = Translator; 4= Fluent; 3 = Good working knowledge; 2 = Limited; 1 = Basic
Language Speak (Provide Level) Read (Provide Level) Write (Provide Level)
Khmer 5 5 5
English 4 4 4

12. Special qualifications and skills:

List any special skills you possess and equipment you can use, certifications, licenses obtained, etc.
Speaking and communication
13. Training Received:

List training received in areas applicable to the internship position in which you are applying.
Development Outreach and Communications Intern

14. Employment (Paid or Voluntary): Please list your most current work experience.
A. Name and full address of employer: Kry Lyheng

B. Dates Worked From November/12/2019 To: 20/September/2020
(month/day/year):
C. Exact Title of Position: English Teacher Number of hours worked per week: 8h/week
D. Supervisor’s Name and Contact Information
Name:
Title: Telephone number:

E. Describe main duties and responsibilities:
Educating young students
Managing Students and Classroom
Good Manner with high responsibilities
F. Number of employees you supervised: 01
G. Reason for leaving: To explore and learn more about careers related to future goals
15. Have you ever worked for the U.S. Government? Yes No
Have you ever been dismissed or forced to resign from a position? Yes No
If yes, please explain:
16. Computer Skills
How do you rate your computer skills:

5 = Excellent; 3 = Good; 1 = Fair; 0 = None
Computer Programs Rating
Sony Vegas 3
Microsoft Word 3
Microsof Power Point 3
After Effect 1
Photoshop 1
17. References: List three persons not related to you by blood or marriage who are qualified to supply definite information regarding
your character and suitability for employment under the program. Do NOT include former employers (i.e.,
supervisors).
Name Address Telephone Number Occupation
Serey Sath Phnom Penh 095321504 Student
Sok Hok Phnom Penh 093550577 Student
Ngoun Sok Heng Phnom Penh 089450607 Student
18. You must sign this application. Read the following carefully before you sign.
I am a current student at a trade school, technical or vocational institute, junior college, college, university or other
accredited educational institution, and I am in good academic standing.
I understand that any information I provide may be investigated and that any false statements may be grounds for non-
consideration or termination from the FNSIP, if selected.
I understand that, if I am provisionally selected for the FNSIP, a successful security and medical certification must be
completed before I may begin the program.
I consent to the release of information about my ability and fitness for the FNSIP by employers, schools, law enforcement
agencies, and other individuals and organizations to U.S. mission-authorized investigators and personnel.
I certify that, to the best of my knowledge, all of my statements are true and complete.

_____________________________________________
Printed Name of Applicant
Lyheng 05/November/2020
_____________________________________________ ________________________________
Signature Date

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U.S.

MISSION PHNOM PENH

1. Position No. /Title:

4. Last Name (Surname): Lyheng First Name: Kry

5. Present Address: PhnomPenh

6. Telephone number: 069973161 Email address: [email protected]

7. How did you learn about this program?

Job Advertisements Employee

Other (Please Specify):

Name Relationship Agency, Position

10. University/school/education institution:

10a. Name of school: Institute of Foreign Languages

Address: Russian Federation Blvd. Phnom Penh

Instructor’s name and contact information:

Name: Title:

Telephone number:

10b. Name of school: Cheasim Samkaky

Instructor’s name and contact information:

Name: Title:

Telephone number:

12. Special qualifications and skills:

Speaking and communication

13. Training Received:

Development Outreach and Communications Intern

A. Name and full address of employer: Kry Lyheng

D. Supervisor’s Name and Contact Information

Title: Telephone number:

F. Number of employees you supervised: 01

If yes, please explain:

16. Computer Skills

How do you rate your computer skills:

Computer Programs Rating

Microsof Power Point 3

Serey Sath Phnom Penh 095321504 Student

Sok Hok Phnom Penh 093550577 Student

Ngoun Sok Heng Phnom Penh 089450607 Student

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