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Lri'3u ri'3n~6) ~ti1'\.J'llln1 1V1tl'llli'\.J~Jl1'Vi~V1fti'flLl.J1n1 iJ1::LY1F'l1Ylll ti ~ ; 1ci1 .. ....... ..... .. ... _ ...•... •- · - --· Youth in Development (YinD) Group 128 Site Application Form Annually Peace Corps places approximately 35 Volunteers to work alongside Thai counterparts in SAO/ Tessbaban/SchooVCommunity Health Promotion Hospital. This application is a screening tool for selecting promising sites for placing those Volunteers. u~<1::ihnhvti'u~ml'l'1 ri~tmnrriiti1~1u1u1.h::1rnu 35 tiu 1~vli1~1uli'1u011'ii'llu1w11'llu1111nrn~vu1111~1u'b'l1,.rwiuvur11mffm<1 h~ifou 1m::l'lfl!l lYtn'fl. ·. i lJ n'1J...fl l ll~ 'il:: l 'lltiJll 'IJ !ll;jlll ll 01ll'I~11 Wlfl fl Lll!l nl'I ll'l'lil{JlJfl ~lll 'IJ !l~ !lln'ln'1Jfl l )Id " - .. • " ...: ... . - .. n1ru iti ru~i'.ium'J'llD~11orn1rrilm 11f1'li'11110~1nr~wil1.J fiuu~11~nrnn 1rni1'llD u1mmrn'J 'hhhcnJfitl'~ rn.i 1u11u1u~1u llD ~lhu i 1wl1J nti10~11~gulu1fo~~u niu h~~ou !!l,'l~ ·ni.m1.101.J1lTu mru1r1'.ion1ufi1'llodi1unm~ni1~ ou\:l./mfflJli,'j/1rn1owm.rrci.1ou1ifo . i;1J~ ~·~~ 11~;t1·iu*11r10 ~i~i i1;~iJu~1~u~ij1f·~un11~11f'11~1ilutt~~n~·utf1u 1u11n.11~1~u~1ijfi11l otr I... I . • • • • • irnt: • n-nu1~-:iirnnTri1fiw1'W1'W~ 3o ~imi~~· ~:fl. 2'558 - !It .-- • - :-~~-;· :-.,· •. . ·: ; •. :-' ..... :~.;'·.;.;~'.>.:·-·).',~-:.,.·.:~'-~.:·'~~..::-,~_-;;· ..·., ~- . - .. 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L'YJ'.iffl'jYliieii'iei: Lflel'W ,.. ~QI - ~ l'W fl l'WW11'.Jn.J YI '.i'U P-1 fl 'lfel'U: Peace Corps Thailand 242 Rajavithi Road, Dusit, Bangkok 10300 Tel. 02-2430140 Fax. 02-2435777 l1U1fltl'U~tn'l'lfl'l1S!m1J'lfl11h::ll1ffil1v 242 oiiiin111ii t'llfl~iYfl n1~ll1V1"1 103001m . 02-2430140 1mtT11 02-2435777 4 '1ffJIHlWU (f111JW.Jnq11): .; ., 'lffl- lJ 7llft'f) Z! 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'\" .e:I 'IHl'!ffllU"Jflnn 1~.:i1·mu : 1.,,'iff'Ylnihiih:i: ... 1:::u:::mnmnJB~.:i1u '4 t' .et l~tl'U .d ., '1fCJ-?J1JJft'f}ll(fl1'tJWWqY) : .., 2fl'JIHIW'll (111't11B.JflqY): .J ' Vl?lEJ .J (111'1:t11'VltJ): Position ~lll'lftk ~ ' ~I 'Vl?!EJ (111'1:t1?l·:mqi;): Age tl1:::L!l'VlLN~tiu: Dtl1:::mJ D'llmti'l?lm~ OiTfitill Degree/Majoring: 1Wlnntrmnt1'll'1ltlfl : tll~ : u Teaching Subjectffti'U1'll'l: # .. Teaching level fftl'U'i:::i'll'lf'U : ...?l ~ " Telephone 1'Yllff'Yl'Vl: LlJ~ : Mobile Phone ht'iff'YITiiiti~tl : L11.JL'llr;l: 41uriui.Jn~tiu~i1mm:::'-l~1.:i ' 4 ,, 0 ~ 11-1 s ti Email atlJ'1 : iJ ... l~tl'U ct 'llfl'!f61U"Jflfll~ 1~'3l~fJ'll : 1mff''Ylniiei~ei : 1:::u:::m11mnJB~.:i1u ... l~tl'U Peace Corps Thailand 242 Rajavithi Road, Dusit, Bangkok 10300 Tel. 02-2430140 Fax. 02-2435777 l!U11Jtl\J~tn'l'lt1"t1i'i~m1'lm 1.h::rnffi-rw 242 ouun1tifi t'll~~iY~ n:-~1l1l'M 103001m . 02-2430140 1mm1 02-2435777 6 ,,j "' ., ., 'lfBHY.irn. (iJUl18WffY): 'ifEJ- lJWfff}fl(IJUIW'3fl'Jll): ~flQ {mm 'hw): Position 9i1U'l1U~: Yiei~ (f111Jl~~f1{)1J) : .. )::V::'Yll~~lf1 8'1J~/L'Ylff1J1CI : "' ": 1'mff'YfYl d .. Degree/Majoring: 11Pllf11rnmntl'lfll8f1: hlnTl) : flllH'I: "' " Telephone1'Yl)ff'Yi'YI: d '1~~": L1'1J Mobile Phone L'YIHlw'l'i'neia8 : Email ~llJCI: . lfltllJ ' "' "" 'llel~81'1-J1£lfll'j':i'VUTVI.: 1'Yl)ff'w'l'i'n8aei : ):;ti::rrn1nm.J~mnu "' . ., ., 'lfBH't. lTPJ. (IJ1ll1BWfJll): '1fV-lJ?JJft'f}fl(IJ1ll1BW'Jll): ~8~ (f111Jll'YIV): Position fi lll'HU ~ : Yiei~ (f111Jl~~f1{)1J): Age ):;v::m~~1n ei'IJ~/L'Ylff'UlCI : Degree/Majoring: 11Pll mrnf11J 1/1'lfll8 f1 : 81~ : .. d .. 1mff'w'l'i': flLlJCI : "' " : Telephone 'iL'YJ)f!"Yi'YI d '1 ~~: " L1'1J Mobile Phone 1mffrl'l'i';j8G8 : Email ~llJCI: . lflfllJ "' "" 'lf8~ell'l..!1£JfllnVUl'VI.: 1 'Yl~ff'w'l'i'neiaei : 'il 'Yl)ff'Yi'Yl'UllJ "' " " : )::v::rrn1mnJ~llii~1u . lflfllJ Peace Corps Thailand 242 Rajavithi Road, Dusit, Bangkok 10300 Tel. 02-2430140 Fax. 02-2435777 'ttlJ1fltY'U~fl1l'4tl"l1f~mlJ~n1 US::tllfl',Ylfl 242 tl'U'Un'Y1fi l'IJ~~ff~ 0!~1Yll'4"1 10300 1m. 02-2430140 1mtYn 02-2435777 7 D fffllW11'lfW ... fl'W 'b'lfJ Llntl'W fl'W 'b'lfJ .. Li;Jfl'W fl'W 'b'lfJ ... ... ., 'lffJ- lJlllff fJ Cl(!)1'!11 B.J flf.J11) : ., 'lffJ- lJWfff}'1(m11wwq11) : .. 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Mobile lJfl()fl : Email flLlrn: . . v~ ' 'tt'Ul'Yll'UOt'll.J: How can volunte~r .help your community 01mmrm\l::mi1m1'li1ul"l1,1fi'Utmim'Mmi13 l~iJ13 1 Peace Corps Thailand 242 Rajavithi Road, Dusit, Bangkok 10300 Tel. 02-2430140 Fax. 02-2435777 '11U1t1ti't1~fll'IHY'l1I!'flllJ°1m 1h::rnffhw 242 flt1t1s1'1f1ti ,,,~~u~ Ol~l'l'lYM 103001m. 02-2430140 hinns 02-2435777 8 Please list all youth development projects in the Annual budget plan that expects to work with volunteer T1Jrn~::1Jlm~n1wli'urr~mTNr~llftflUflnuunnJ1imrmlom1/immh::~1iJrlfl1ottl'~il::li1rnril1Ji1uDmmiJm In 2 years wh~t changes or improved skills you would like !o see in your local youth and community ' tl ' ~ 1 t=t v v ri::s .. 1 1im:m:mn 2 ul'll'lHrn11mm1rrm:tJm fllll'JJfl1rnmvi111.:imllm11ut1Ull!lu1'l.:i'llo.:imn'lfu11n~l"'lfll'lJO.:imuotn.:i ':i ci c ' - -;_ - ' -- : I - , "~' ~ / --· - } ; ' r, _f f. - Cl.I - - ~ ;:_, \ - - -- l C! , J ; ~ " ~ f ., \ : ' " -·-- -1 - ' ; Communications fll':i~vi~o~o!:T11: 24·hour working landline jjhi1ff''l'IYl,iu!1u~9i~PivM 24 ~ll. Available mobile service G ~ 1 • -- f j ... ~ _rr ' I .. ~ -- -- D Yes jj D Nohm 'I 1 -- - - - --~ -- -- - - ~-- --- -- -------~-- ---- ----- If yes, please put the number _ _ ihjj nrn.m::1p.n.nmft'll LYll'~Yrvi" DAIS D True D DTAC utt~~1w1Yl1ff'1'1Yluvov Overseas call tT1ll11fl 1mm~1mm:ldmh::rnnM D Yesl'.l D No 1iijj Post Office ~Yi1ri111un1wil km. Distance from SAO!fessaban 1::v:: m~111nvu~ .1rnn111n (fill.) Internet Access at school jj~\Jl~vfril~~1H~IJ\J Distance from Tambon/to A.Muang _ _ km. Travel time to A.Muang _ _ hours. r::u::vrn "11n1-1~u1wii..i ti .Li'.itM 1~L'lft1L~Ul'l1'1tlr::irnu ('Dl.J.} Distance from Tambon/to Bangkok ·_ __ km. Travel time from Tambon/to Bangkok _ _ hours. r::u::vrn "11nJii..i nt..iLl'lm 1~l'lft1l~um..itlr::irnu ('lll.J.) ... A.Muang tl.LlJtl'I :__ Bangkok f11.:Jl'Yl'Yt"I : __ Peace Corps Thailand 242 Rajavithi Road, Dusit, Bangkok I 0300 Tel. 02-2430140 Fax. 02-2435777 l1U1rJttu9im'l'ltTl1f!Vllllnl u1::mff1Ylv 242 fl\J\J11'!fi0 l'IJA~iYA fl'j~tn'l'l'1 103001m. 02-2430140 1mtTn 02-2435777 9 D Yes ii D No1iiii Bus rnuu ___times per day .J ' v LYIU'l(;]tl'lU To your district fi1'ei1urn :__ . A.Muang 6.LlHM:__ Bangkok fl1'11'Yl'Yi'1 : __ D Yes ii D No1iiii Van rn~ _ _times per day .J ' v Ll'JU'l(;]tl'lU To your district fi1'ei1urn: __· .· ... A.Muang 6.1lJ6'1:__ Bangkok fl1'11'Yl'Yi'1: __ D Yes ii D No1iiii Train sohl _ _times per day .J ' v Ll'JU'l(;]tl'lU Depart from ~imnumil: D Yes ii D No1iiii Airplane lfl~a~uu ... A.Muang 6.nrn.:i :__ Bangkok fl1'11'Yl'Yi'1: __ _ _times per day Bangkok fl1'1L'Yl'Yi'1: __ .J ' v LYIU'l(;]tl'lU Emergency transportation D Yes ii D No1iiii Mode of Transportation L~'W'Yll'l L'1fl __ mn~um.J~mZlu D Yes ii D No1iiii Counterpart's vehicle ..SOIYia'Ul1lNl'U'lfl1 .. hw Bank Ii'UlfllS D Yes i:i D No1iiii Nearest A TM Booths ~n~1~u~1u~iml'~tt~ D Bangkok 1i.fl1'11'1'1Yl 1i.fl1'1l'l'lfl ~~ ~ Intemet Ci:tie ... D D Kasikom li.flffml'Ylfl TMB1i.'Yll11'il'l'lfl SCBli.l'l'lfl'YiltU'J)'fl D D Others~'W'l D __ D Yes i:i D No1iiii fnn~u~/~tl1~ir~ Convenient Shop/ Seven Eleven f 1uu::~1n~a Local NGO/ Government Office 'ttli1v~1ui'1/ti.Jf'1nr D Yes i:i D No1iiii 'WuA'l.Jii1t.ifH11Muwu~ Tourist Attraction umu~Yia~1~v1 Nearest private hospital D Yes i:i D No1iiii Telephone number 1'Yl'L L'i '!'Yi u1rn'1Lflfl'lf'W~6d'tn"~"J''1 Nearest government hospital 1'i -3Ylu1rn'1~jrn'1~6~'tn"~"J''1 Krung Thai . Bank of Ayudthya 1i.fl1'1ff6~~fll D Yes i:i D No1iiii d s1u6ul,9Yas1u~ Fresh market D If yes, please specify the nearest Bank Telephone number 1'Yl'L Peace Corps Thailand 242 Rajavithi Road, Dusit, Bangkok I 0300 Tel. 02-2430140 Fax. 02-2435777 'HU1VtY'U~flll'lfl''Hl!611Jlnl tls::1Y1ffhw 242 O'U'USl'lf~ l'U~~iY~ f)~~IYIYl"1 103001m. 02-2430140 1mfl'1S 02-2435777 10 - c.ommunity Safety risks/incidences m1ll1~v.:i.fivi'W'l[ll'lf'U 1 iJ·rn)::'lJ: Natural disaster risks (flooding, earthquake, landslides) m1m~v.:ii'Um)1nri~'Yln.fiv 11~eififJli)nJ'lfl~ 1i..l)fl)::'lJ: Political/social stability or climate nmiiei.:il1'ei.:i~'U lrn::n-.nwn1.:ifllJ 1riai1 '1iJ~m1mJw•1.:i1i1tM i) 1iJ)rieinma: Neai:est police station ffmi1~1)1'1~ei~ina~irritiei: Address ~ ei ~: Telephone number 1m.: I ' . • •• • • ~ .: :. • • ! • .' • • ~ • • • • • • : • ·: I I 4 I '])'eJ-ffmi . . 'U lfJfi el'lJ fl ./'U lfJflL 'Y1 i'l'lJ'U I I II I • • , · •• ~ • I t'llfJlJel'lfeJ: ~ d • " 1 • • • • • ... 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