Work Placement

A. Background Information (Respond or Tick)1. Full Name

2. Contact information

Tel 1:Tel 2:Email (Optional)3. Gender Male Female4. Nationality Ugandan Refugee5. Please indicate your National Identification Number (NIN) or Refugee Number NIN Refugee NumberNIN Refugee NumberB. Business Information6. Type of Business (e.g. salon, tailoring, catering etc.)7. Are you a business owner or an employee? Business Owner Employee8. Annual revenue generated by the business in UGX 5 to 10m 10 – 20m 50m and above9. Indicate the number of employees 1 – 4 5 – 49 50 and above

C. Information on Placement

10. What skills would you like to improve through the work placement?11. Why do you want to pursue the work placement?12. What is your preferred start date?13. Are you available full time? 14. How much time are you willing to commit to this work placement opportunity?

15. Business Location

District/City/Settlement: Subcounty/Division/RWCIII:Parish/Ward/RWCII:Village/ cell/zone/RWCI:

D. Disability

16. Do you have any disability? Yes No17. If yes, please choose the category of disability: None Hearing Disability Mental Disability Physical Disability Visual Disability Albinism Little People Others (Specify) Others (Specify)

E. Confirmation

I declare and confirm that the information provided above is true and accurate to the best of my knowledge.

Signature:Date:Submit