INFORMATIONAL APPLICATION
CORE JOURNEY TO VIET NAM: FALL 2018
Please note that this is information needed only to organize travel with a group of veterans and civilians to Viet Nam. This is the first step in the process, which may also involve a personal conference call with the trip facilitators who will accompany the group and offer mentoring before, during, and after the trip. Details of how the travel experience is conducted will be explained during the call, however you may call before sending this information if desired; 303-909-8336.
FULL NAME:
____________________________________________________________________________________
(exactly as it appears on your passport)
PASSPORT NUMBER and DATE OF EXPIRATION
________________________________________________________________
A passport is necessary for travel to Viet Nam. If you don’t have one when will you be applying for one?
___________________________________________________________________
DATE OF BIRTH _______/_______/_______
STREET ADDRESS
____________________________________________________________________________________
CITY, STATE, ZIP
____________________________________________________________________________________
BEST TELEPHONE NUMBER
___________________________________________________________________________________
EMAIL ADDRESS
____________________________________________________________________________________
HOW DID YOU LEARN ABOUT THIS TRIP?
____________________________________________________________________________________
____________________________________________________________________________________
TYPE OF WORK
____________________________________________________________________________________
(present and/or former)
EDUCATION (any degrees)
____________________________________________________________________________________
WHY DO YOU WANT TO TRAVEL TO VIET NAM?
____________________________________________________________________________________
____________________________________________________________________________________
(expectations for the trip)
MEDICAL EMERGENCY CONTACT PERSON
___________________________________________________________________________________
CONTACT PERSON BEST TELEPHONE AND EMAIL
___________________________________________________________________________________
DO YOU HAVE HEALTH ISSUES THE TRIP FACILITATORS SHOULD BE AWARE OF?
___________________________________________________________________________________
____________________________________________________________________________________
WHAT ELSE WOULD YOU LIKE TO ADD?
___________________________________________________________________________________
____________________________________________________________________________________
VETERAN QUESTIONS
(non veterans please continue at the bottom of the application for signature)
WHAT BRANCH OF THE MILITARY DID YOU SERVE?
__________________________________________________
WHAT WERE YOUR DUTIES?
___________________________________________________________________________________
___________________________________________________________________________________
IF YOU SERVED IN A WAR, WHERE, WHAT UNIT, WHEN?
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
DO YOU HAVE ANY ILLNESS/DISABILITY FROM THE WAR? (IF SO, PLEASE EXPLAIN)
____________________________________________________________________________________
____________________________________________________________________________________
(include emotional and chemical exposure disability)
IF YOU SERVED IN VIETNAM, WHAT WOULD YOU LIKE TO SEE OR DO ON THIS TRIP?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
FUNDS ARE AVAILABLE TO VETERANS NEEDING ASSISTANCE ON THE TOTAL TRIP COST OF $2,750.
WILL YOU NEED A REDUCTION AND, IF SO, HOW MUCH WILL YOU NEED?
____________________________________________________________________________________
ALL APPLICANTS PLEASE COMPLETE SIGNATURE PORTION
_____________________________________________________
PRINT NAME
_____________________________________________________
SIGNATURE
_____________________________________________________
DATE
Please print and mail completed application to: CORE,
c/o Dr. John Fisher, PO Box 11, Jefferson, ME 04348
You may also scan a personally SIGNED digital copy and email to:
CORE Viet Nam 