Peace Corps Sierra Leone is recruiting to fill the following positions:
1.) Medical Assistant
2.) Programming and Training Assistant Health
See job details and how to apply below.
1.) Medical Assistant
SCOPE OF WORK
(Recruitment, PSC Duties, and Performance Reviews)
Organization
US Government – Peace Corps Sierra Leone
PSC Position Title
Medical Assistant
Reports To
Country Director
Supervises
N/A
Annual Base Salary
66,881,075 SLL
Contract Type
Full-Time, 40 Hours per Week
Duty Location
Freetown, Sierra Leone
1. Minimum Requirements / Qualifications for Effective Performance
At a minimum, the successful candidate’s CV must demonstrate the following:
∙ Education: Successful completion of a nursing school (technical/university degree), general medical school, or medical assistant program, and valid registered clinical license/diploma or applicable knowledge and experience obtained through on-the-job training under the direct guidance of a provider (supporting documentation must be submitted).
∙ Multi-Cultural Experience: Minimum of one year interacting in a work setting with diverse cultures. ∙ Work Experience: Two years progressively responsible related experience with knowledge of administrative medical duties related to health services.
∙ Language: English fluency required. Proficiency in oral and written English and Krio.
∙ Administrative Experience: Basic knowledge of administration of health units/facilities, including procurement of medical supplies and inventory control.
∙ Technology: The use of standard office technology (desktop computer, mouse, and keyboard) to complete daily tasks and long-term projects is expected. Working knowledge of Microsoft Windows and Office programs (Outlook, Word, Excel, etc.) is also required.
2. Preferred Requirements;
N/A
3. Background
The mission of Peace Corps worldwide is to promote peace and friendship. Peace Corps was invited to Sierra Leone in 1962, since then hundreds of Peace Corps Volunteers has worked in the fields of Education, Health, Agriculture community development etc. The work of Peace Corps Contractor does not limit itself to the role: active support of the Peace Corps mission is paramount to the job because contractors are representatives of Peace Corps in Sierra Leone.
Peace Corps’ mission is to promote Peace and friendship by fulfilling three goals:
∙ To help the people of interested countries in meeting their need for trained men and women ∙ To help promote a better understanding of Americans on the part of the peoples served
∙ To help promote a better understanding of other peoples on the part of Americans
4. Objective of the Position
This position performs a variety of clinical and administrative duties in support of the Health Unit. The Medical Assistant (MA) works under the guidance of Peace Corps Medical Officers (PCMOs) and reports to the Country Director (CD) for administrative issues (unless CD authorizes PCMO supervision).
The MA is responsible for providing administrative support and, to the extent credentialed, clinical support, including but not limited to; working as the health unit receptionist, actively assisting the PCMOs in clinical care*, screening phone calls, taking messages, coordinating requests, scheduling medical appointments, distributing of medicines to Peace Corps Volunteers (PCVs) under PCMO oversight, and other clerical and administrative functions in support of the PCMOs.
* Clinical duties will be performed with clinical oversight by the PCMOs and only as approved by the Medical Director through the Credentialing Committee/Office of Health Services (OHS).
5. Tasks & Deliverables
MAJOR DUTIES AND RESPONSIBILITIES
ATTACHMENT I
Support to the Health Unit
The Medical Assistant coordinates responsibilities directly with the PCMOs. The MA must adhere to confidentiality regarding PCVs medical issues and possess excellent interpersonal and administrative skills. Clinical Support
∙ Performs a variety of non-invasive routine clinical and technical services under the supervision of the PCMOs, which may include clinical tasks such as taking vital signs, administering immunizations, performing laboratory tests, etc. These privileges must be approved by the Medical Director/OHS. Supervising PCMOs are responsible to ensure that MAs perform appropriate health care services. Even under supervision, MAs are not allowed to assist with or perform any unapproved services.
∙ Responsible for sterilization of equipment.
∙ Serves as chaperone for PCMOs during PCV medical examinations and procedures.
Administrative Support
∙ Screens phone calls and takes messages when PCMOs are unavailable.
∙ Places and returns telephone calls for the Health Unit, including scheduling, modifying, and canceling appointments in coordination with PCVs, PCMOs, and others (including consultants and laboratories). ∙ Follows-up on outstanding consultant and laboratory reports, ensuring this information is relayed to the PCMOs for review.
∙ Drafts correspondence such as letters, memos, and fax covers, etc. at the request of the PCMOs to consultants, PCVs, laboratories, hospitals, etc.
∙ Routes incoming correspondence to PCMOs, stamps and files correspondence.
∙ Utilizes PCMEDICS to assist the PCMOs and backup provider in the documentation and delivery of PCV health care, and to document clinical care given as trained.
∙ Responsible for scanning, labeling, uploading and filing all documents into PCMEDICS after PCMO review and signature, also ensures that three PCV identifiers are on each page of each document.
∙ Prepares envelopes and packages, including laboratory samples and medical supplies, to be sent to PCVs, training sites, and other destinations, and forwards them to the appropriate administrative staff for delivery. ∙ Responsible for photocopying health forms, medical presentation materials and other related documents. ∙ Responsible for requesting office supplies and materials for use in the Health Unit.
∙ Regularly updates the list of medical facilities and medical service providers under the instruction and oversight by the PCMOs.
∙ Assists PCMOs in reviewing the Volunteer Health Handbook given to PCVs during Pre-Service Training (PST). Updates medical facilities and medical providers’ addresses, contact information, and any other information required in this Handbook.
∙ Manages the health information materials in the Health Unit available to PCV, stocking brochures, pamphlets and books. Keeps a detailed list of any books and/or media materials loaned out.
∙ Responsible for receiving and registering all medical bills submitted by PCVs and local medical service providers. Submits bills to PCMOs for approval, verifying name of PCV, date of services rendered, and that all billed services were requested by the PCMOs.
∙ Keeps updated files of all medical bills presented by PCVs and others.
∙ Maintains Volunteer database with up-to-date information regarding PCVs out of site for medical purposes. ∙ Uploads PCV passport face pages and visa pages into PCMEDICS, monitoring regularly to assure accurate and current information.
Medical Supply Duties
∙ Maintains internal medical inventory for the medical unit, ensuring an adequate supply of disposable materials and keeping PCMOs informed.
∙ Responsible for updating internal medical inventory system (as determined by the PCMOs) when medication/supplies are delivered, dispensed and destroyed.
∙ Assists the Acceptance Point Clerk (APC) when medical supplies are received.
∙ Provides documentation to the Medical Supply Inventory Control Clerk (MSICC) on receiving, dispensing and disposing of specially designated medications and controlled substances.
∙ Keeps an accurate control of the expiration dates of all medicines and alerts the PCMOs of upcoming expired medications. Removes expired items from the pharmacy and logs all items scheduled for disposal. ∙ Responsible for organization and shelving of Health Unit supplies.
∙ Assists PCMOs with PCV medical supply requests.
∙ Prepares draft orders for medical supplies, with PCMO guidance, based on needs, historical data, and inventory availability. Assists the PCMOs in ordering medical supplies from PC/HQ and local/regional vendors.
ATTACHMENT I
∙ Maintains files, according to fiscal year, of all ordering, receiving and dispensing documents in compliance with Technical Guideline 240: Medical Supplies and Equipment.
∙ Assists PCMOs in the monitoring of the medical supplies budget.
Other Duties
∙ Attends staff meetings, in-service trainings, and retreats when indicated.
∙ Understands and complies with Peace Corps safety and security policies and procedures. ∙ Understands and complies with Peace Corps code of ethics, privacy and confidentiality policies. ∙ Files all documents produced by the position in accordance with the Peace Corps Records Management policies. ∙ Performs other assignments considered as necessary by the PCMOs in consultation with the CD, as indicated.
6. Standard Roles and Responsibilities
A. OMH:
∙ Occasional Money Handler may be requested to courier cash and /or purchase orders to various vendors who furnish supplies and/or services to PST/IST training site, or other locations as directed by the Contracting Officer. The PSC may also be requested to courier cash to PC trainees or volunteers. The PSC will not be functioning as a procurement or disbursing official but will only be acting as an intermediary between the Contracting or Disbursing Officer and the recipient. In the case of dealing with vendors, the PSC will not exercise any procurement discretion concerning the supplies or services to be purchased or the cost limits of these purchases; these will be determined by the Contracting Officer.
B. S&S:
∙ Employees with no SPECIFIC Safety and Security Responsibilities (i.e., cashier, admin staff) – Immediately communicates Volunteer safety and security concerns and issues to the Safety and Security Manager (SSM) and CD. Knowledgeable and supportive of Peace Corps safety and security policies and procedures, including the timely reporting of suspicious incidents, persons or articles.
C. IGF:
∙ N/A
D. Temporary Assignments:
∙ Given that as a result of the COVID-19 pandemic there will be a lengthy period where there are likely to be limited or no Peace Corps Trainees and/or Volunteers (jointly referred to as “Volunteers”) at Peace Corps/[Country], the PSC may be temporarily assigned during the COVID-19 pandemic, as determined by the Peace Corps Director, to carry out additional duties and responsibilities in furtherance of the goals of the Peace Corps in order to enhance the ability of Peace Corps Volunteers to perform functions under the Peace Corps Act, including facilitating a safe environment in order for the successful return of Volunteers.
This temporary assignment may require the PSC to provide services and/or support beyond what is listed in their current Statement of Work (SOW). The services and/or support may take many forms, examples of which may include but are not limited to, training, providing administrative, technical, medical, and/or operational assistance, building on host country programs, etc. This temporary assignment also may require the PSC to provide these services and/or support to individuals/organizations other than those listed in their current SOW such as host country government, partner organization(s), community member(s), staff, and/or contractors.”
7. Logistics & Level of Effort & Duty Station
Duty station is the office in Freetown. May be required to work in another town during training (typically taking place over 11 weeks in the summer, subject to revisions as needed). May also be required to travel up country as needed, including on short notice. Performs duties during a 40 hour work week. Events may require occasional work in the evenings and on weekends and holidays. May carry a duty phone.
8. Application Requirements
Application deadline is on January 26Th 2022 at 5:00 PM.
In order to be considered for this position, the applicant must;
1. Be a Sierra Leone Citizen with residency, and must not have been employed in intelligence-related activities.
ATTACHMENT I
2. Submit complete application package on/before the application deadline date and time by email to: : SL pcjobs@peacecorps.gov or by hand to HR Specialist, Peace Corps/Sierra Leone, 34 Old Railway Line, Signal Hill, Freetown, Sierra. Application must include the following;
▪ A letter of interest addressing the required qualifications.
▪ A complete CV, to include:
∙ All relevant employment, including start and end dates (month and year) for each position listed, and a summary of key tasks and responsibilities for each position.
∙ Educational background and a list of current license(s) held (type of license, dates of
issue/expiration as applicable), and/or a detailed description of equivalent experience
obtained through on-the-job training.
∙ Contact information (name, email and/or phone number) of three professional references. At least one reference must be a current or former supervisor. Peace Corps may request
additional/other references.
∙ Information regarding citizenship and work authorization in Sierra Leone. All candidates selected for interview will be required to produce a Government-issued ID card/National
Passport/ voters ID card for review.
∙ All education, experience, skills and qualifications will be verified.
3. Include completed checklist (Attachment I) of detailed Job requirement in application package.
All experience, skills and qualifications will be verified. Applicants with high potential will be scheduled for an interview at the Peace Corps office in Freetown. Employment is contingent on a favorable security background and medical check.
Please include “Ref: Medical Assistant” on the envelope submission and or in the subject line for on-line application.
Note: This vacancy advertisement supersedes the advert that was sent out earlier
APPLICATION CHECKLIST
All applicants wishing to apply for any Peace Corps job is required to provide the following information below and submit with your application package.
Name of Applicant: ___________________________________________________________ Position you are applying for: ______________________________________________________
Details YES NO 1. Have you ever served Peace Corps as a Trainee or Volunteer (Including Response or Virtual)? If so, please specify______________________________________________________
2. Have you ever being employed as a Peace Corps staff member (US Direct Hire (USDH), Personal Service Contractor (PSC), Foreign Service National (FSN))?
If so, please specify______________________________________________________
3. If your answer to any of the questions above is yes please provide the following information below;
∙ Position location:________________________________________________________ ∙ Position type: ___________________________________________________________ ∙ Title: __________________________________________________________________ ∙ Start date: ______________________________________________________________ ∙ End date: ______________________________________________________________
____________________________________________ _____________________ Signature of Applicant Date
2.) Programming and Training Assistant Health
SCOPE OF WORK
(Recruitment, PSC Duties, and Performance Reviews)
Organization
US Government – Peace Corps Sierra Leone
PSC Position Title
Programming and Training Assistant Health
Reports To
Program Manager Health
Supervises
N/A
Annual Base Salary
92,883,697.00 SLL
Contract Type
Full-Time, 40 Hours per Week
Duty Location
Freetown, Sierra Leone
1. Minimum Requirements:
At a minimum, the successful candidate’s CV must demonstrate the following:
∙ Education: University degree in public health or a field of study relevant for projects in community health ∙ Years of Experience: At least 3 years’ experience in community health working with relevant government agencies, NGOs, or private enterprises
∙ At least 1 years’ experience in training delivery or community outreach using adult education methods ∙ At least 1 years’ experience working within a multicultural organization
∙ Job experience in a position that requires working independently with limited supervision
∙ Extremely organized and detail-oriented
∙ Ability to design, implement, and evaluate program activities
∙ Ability to engage in both intellectual and manual endeavors
∙ Proficiency in oral and written English and Krio.
∙ Experience working in a cross-cultural environment
∙ Proficient in MS Office computer applications (Word, Excel, Outlook).
2. Preferred Requirements;
N/A
3. Background
The mission of Peace Corps worldwide is to promote peace and friendship. Peace Corps was invited to Sierra Leone in 1962, since then hundreds of Peace Corps Volunteers has worked in the fields of Education, Health, Agriculture community development etc. The work of Peace Corps Contractor does not limit itself to the role: active support of the Peace Corps mission is paramount to the job because contractors are representatives of Peace Corps in Sierra Leone.
Peace Corps’ mission is to promote Peace and friendship by fulfilling three goals:
∙ To help the people of interested countries in meeting their need for trained men and women
∙ To help promote a better understanding of Americans on the part of the peoples served
∙ To help promote a better understanding of other peoples on the part of Americans
4. Objective of the Position
The Programming and Training Assistant (PTA) serves as the principal technical associate for Peace Corps Sierra Leone’s Health Project. The incumbent will support the Program Manager (PM) and works as part of a team collaborating with the Programming and Training Unit. The PTA will actively contribute to the design, implementation, and evaluation of program activities and correlated trainings for the health project. The Health PTA will support the PM in the planning, researching, managing and evaluation of the Health program and assists in providing technical and administrative support to Peace Corps Volunteers (PCVs) and Trainees. The Health PTA also serves as the head technical trainer during Pre-Service and In-Service trainings (PST/IST), enabling training and programming to be fully integrated into the Health program. Additional responsibilities include managing the Volunteer Reporting Process which includes training, trouble shooting, reporting and coordination with all post staff and Volunteers. The incumbent is authorized to act as Occasional Money Handler.
5. Tasks & Deliverables
Trainings:
∙ Coordinate with PM and the other training staff on the design, implementation, and evaluation of the Pre-Service and In-Service Training events for Health project. This includes identifying relevant competencies, identifying human and material resources, assessing PCT/V needs, and drafting a training continuum for PCVs.
∙ Design, deliver, and evaluate the technical training for Health project. All training must be aligned with project goals and objectives including collaboration with all facilitators, solicitation of guest speakers, and communication with the TM on any training costs.
ATTACHMENT I
∙ Participate, as agreed upon with the PM, and TM, in all training events. This would include preparatory Training of Trainers (TOT), ongoing evaluation meetings, and debrief meetings.
∙ Leads the Training of Trainers for the Health component of the training group.
∙ Monitor and evaluate qualifications of each Peace Corps Trainee (PCT) during and at the end of PST, particularly as related to the technical component of training.
∙ Collaborate with the PM, and training staff to assess PCT competence for service.
∙ Assist the PM to complete timely initial and site placement interviews with PCTs.
∙ Assist the PM to conduct PCV meetings
Volunteer Support:
∙ Travel regularly throughout the country to establish and maintain effective working relationships with sponsoring organizations and community officials.
∙ Visit Volunteers periodically at their sites to offer advice and assistance to them and their counterparts/supervisors in order to enhance working relationships and performance.
∙ Document activities and results in regular site visit reports.
∙ Assist Volunteers in improving their job performance and their social and cultural adaptation through the provision of technical support, cultural insights, and direction to relevant and available resources.
∙ Support Volunteers with personal and cultural counseling and guidance on various policies and procedures. ∙ Coordinate with the safety and security staff as well as with the medical unit to advise Volunteers on safety and security issues.
∙ Maintain up-to-date information regarding relevant legislation; national policy changes; contact lists of relevant local organizations, institutions, and agencies; and other published resources including reference texts, professional journals and other similar information; and make the information readily available to Volunteers.
∙ Serve as resource person for PCVs regarding technical, logistical and moral support for PCVs.
Program Development and Management:
∙ Assist the PM to develop potential assignments for PCVs through community visits and meetings with local representatives of the Ministry of Health and Sanitation (MoHS), potential host health facilities, and community members. Explain Peace Corps Sierra Leone’s development philosophy and the role of the PCV to these stakeholders.
∙ Negotiate and evaluate job viability, available housing, the work environment, the level of host health facility’s interest, and the engagement of the local community.
∙ Assist the PM to initiate and maintain close and effective contacts with national and local representatives of the MoHS, other appropriate government agencies, Non-Governmental Organizations (NGOs) engaged in community health work, and other organizations and groups, public and private, utilizing or likely to utilize PCVs at both the national and local levels.
∙ Monitors MOHS and NGO activities and initiatives in malaria, nutrition, water, sanitation and hygiene. Explores and provides input concerning potential collaboration between Peace Corps, GoSL, and implementing partners. ∙ Represent Peace Corps in negotiations with these stakeholders on the qualifications, numbers, and placement of PCVs. ∙ Assist the PM to design and implement project monitoring and evaluation tools and activities with the participation of appropriate officials, local counterparts, other education agencies, and PCVs. Assure that PCV activities advance Project goals as intended.
∙ Work with the PM to utilize the Volunteer Reporting Tool (VRT) for the entire PCV reporting process: create, send, receive, edit, and acknowledge PCV reports; provide written feedback to PCV; input data from the Volunteer Report Form (VRF) to the Volunteer Report Database. While the Primary and Secondary Education PTA will assist with this duty, final responsibility rests with the PM.
∙ Conducts field visits to provide technical support to PCVs.
∙ Provide site visit reports in a timely manner to PCVs. As requested, provide site visit reports to other Peace Corps Sierra Leone staff and make recommendations regarding Volunteer performance and problems.
Other Duties
∙ Attends staff meetings, in-service trainings, and retreats when indicated.
∙ Understands and complies with Peace Corps safety and security policies and procedures.
∙ Understands and complies with Peace Corps code of ethics, privacy and confidentiality policies. ∙ Files all documents produced by the position in accordance with the Peace Corps Records Management policies. ∙ To the extent Contractor is allowed to operate a US government owned, leased, or rented vehicle (GOV) to perform
their job duties, the Contractor must operate that vehicle safely at all times and only operate it for official business purposes as defined in 31 USC 1334. Contractor is encouraged to refrain from texting or from engaging in any
ATTACHMENT I
behavior that distracts attention from driving safely at any time. Except in an emergency situation, Contractor shall not text message (i) when driving a GOV; (ii) when driving a privately-owned vehicle (POV) while on official government business; or (iii) while using electronic equipment supplied by the government while driving any vehicle (even during off-duty hours).
∙ Performs other assignments or duties as assigned.
6. Standard Roles and Responsibilities
A. OMH:
∙ Occasional Money Handler may be requested to courier cash and /or purchase orders to various vendors who furnish supplies and/or services to PST/IST training site, or other locations as directed by the Contracting Officer. The PSC may also be requested to courier cash to PC trainees or volunteers. The PSC will not be functioning as a procurement or disbursing official but will only be acting as an intermediary between the Contracting or Disbursing Officer and the recipient. In the case of dealing with vendors, the PSC will not exercise any procurement discretion concerning the supplies or services to be purchased or the cost limits of these purchases; these will be determined by the Contracting Officer.
B. S&S:
∙ Other Programming Staff – Addresses Volunteer safety and security by adhering to Peace Corps site development policies and procedures. Identifies and immediately communicates Volunteer safety and security concerns and issues to the Safety and Security Manager (SSM) and the Country Director (CD). Assists Program Managers/APCDs to ensure that prospective sites meet established programmatic and safety/security criteria (e.g., safe housing, a clearly defined assignment with an organization that shows real interest in working with a Volunteer, etc.). Reviews and references site history files when evaluating potential sites, and incorporates appropriate safety and security-related information into site history files. Monitors Volunteer compliance with Peace Corps policies, especially related to safety and security. Participates in the design and implementation of the Emergency Action Plan (EAP). Acts as duty officer, as needed. Knowledgeable and supportive of Peace Corps safety and security policies and procedures, including the timely reporting of suspicious incidents, persons or articles.
C. IGF:
∙ N/A
D. Temporary Assignments:
∙ Given that as a result of the COVID-19 pandemic there will be a lengthy period where there are likely to be limited or no Peace Corps Trainees and/or Volunteers (jointly referred to as “Volunteers”) at Peace Corps/[Country], the PSC may be temporarily assigned during the COVID-19 pandemic, as determined by the Peace Corps Director, to carry out additional duties and responsibilities in furtherance of the goals of the Peace Corps in order to enhance the ability of Peace Corps Volunteers to perform functions under the Peace Corps Act, including facilitating a safe environment in order for the successful return of Volunteers.
This temporary assignment may require the PSC to provide services and/or support beyond what is listed in their current Statement of Work (SOW). The services and/or support may take many forms, examples of which may include but are not limited to, training, providing administrative, technical, medical, and/or operational assistance, building on host country programs, etc. This temporary assignment also may require the PSC to provide these services and/or support to individuals/organizations other than those listed in their current SOW such as host country government, partner organization(s), community member(s), staff, and/or contractors.”
7. Logistics & Level of Effort & Duty Station
Duty station is the office in Freetown. May be required to work in another town during training (typically taking place over 11 weeks in the summer, subject to revisions as needed). May also be required to travel up country as needed, including on short notice. Performs duties during a 40 hour work week. Events may require occasional work in the evenings and on weekends and holidays. May carry a duty phone.
8. Application Requirements;
Application deadline is on January 26th 2022 at 5:00 PM.
In order to be considered for this position, the applicant must;
1. Be a Sierra Leone Citizen with residency, and must not have been employed in intelligence-related activities.
ATTACHMENT I
2. Submit complete application package on/before the application deadline date and time by email to: SL pcjobs@peacecorps.gov or by hand to: HR Specialist, Peace Corps/Sierra Leone, 34 Old Railway Line, Signal Hill, Freetown, Sierra. Application must include the following;
▪ A letter of interest addressing the required qualifications.
▪ A complete CV, to include:
∙ All relevant employment, including start and end dates (month and year) for each position listed, and a summary of key tasks and responsibilities for each position.
∙ Educational background and a list of current license(s) held (type of license, dates of
issue/expiration as applicable), and/or a detailed description of equivalent experience obtained through on-the-job training.
∙ Contact information (name, email and/or phone number) of three professional references. At least one reference must be a current or former supervisor. Peace Corps may request
additional/other references.
∙ Information regarding citizenship and work authorization in Sierra Leone. All candidates
selected for interview will be required to produce a Government-issued ID card/National
Passport/ voters ID card for review.
∙ All education, experience, skills and qualifications will be verified.
3. Include completed checklist (Attachment I) of detailed Job requirement in application package.
All experience, skills and qualifications will be verified. Applicants with high potential will be scheduled for an interview at the Peace Corps office in Freetown. Employment is contingent on a favorable security background and medical check.
Please include “Ref: Programming and Training Assistant Health” on the envelope submission and or in the subject line for on-line application.
Note: This vacancy advertisement supersedes the advert that was sent out earlier
APPLICATION CHECKLIST
All applicants wishing to apply for any Peace Corps job is required to provide the following information below and submit with your application package.
Name of Applicant: ___________________________________________________________
Position you are applying for: ______________________________________________________
Details YES NO 1. Have you ever served Peace Corps as a Trainee or Volunteer (Including Response or Virtual)? If so, please specify______________________________________________________
2. Have you ever being employed as a Peace Corps staff member (US Direct Hire (USDH),
Personal Service Contractor (PSC), Foreign Service National (FSN))?
If so, please specify______________________________________________________
3. If your answer to any of the questions above is yes please provide the following information below;
∙ Position location:________________________________________________________
∙ Position type: ___________________________________________________________
∙ Title: __________________________________________________________________
∙ Start date: ______________________________________________________________
∙ End date: ______________________________________________________________
____________________________________________ _____________________ Signature of Applicant Date
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