Amity Institute Teacher Program Application
I. GENERAL INFORMATION
Last Name(s): Copete Garcia First/Middle Name(s): Omar Dario
Age: 40 Date of Birth: abril 04 1980 Gender: M Marital Status: Single x Married
Month / Day / Year M/F
Country of Birth: Colombia City of Birth: Ciudad Bolivar Country of Citizenship: Colombia
Spouse Last Name(s): Spouse First/Middle Name(s):
Spouse Age: Spouse Date of Birth: Spouse Gender:
Month / Day / Year M/F
Children: Yes x No If yes, number of children: 1 Age(s): 10
Contact Information
Street and Number: carrera 24- 24#25 Barrio las Margaritas City: Quibdo
Country: Colombia Postal Code: Province (if any): Choco
Email: co22rad@[Link] Phone: +573216482248
Are you working with a recruiter, government, If yes, what is the name
or agency to help you find a teaching position? Yes No x
of the person or agency?
II. PROGRAM HISTORY
Have you applied to our program in the past? Yes No x
Have you ever been sponsored by Amity before? Yes No
x
Have you ever participated in another J-visa
Yes No
program before? x
III. POST-SECONDARY EDUCATION
Subject(s) / Field of Study Degree Level
Name of Institution Date of Diploma Country
(U.S. Equivalent)
Universidad tecnológica del Choco English and French Bachelor (BA) Colombia
Choose One
Choose One
Choose One
1
IV. TEACHING LICENSE (or equivalent)
Date Issued: School Level: Primary Secondary Both x
Month / Day / Year
Does your post-secondary diploma qualify you to teach in your home country? Yes x No
V. EMPLOYMENT HISTORY
***List post-degree teaching experience. Do not include work as an assistant, apprentice, or trainee***
Dates of Employment Position School Name Primary or Subject(s) Public or Part-time or
(i.e. MARCH 2006- (i.e. 3rd grade teacher) and Country Secondary taught Private School Full-Time
JAN 2010) Level
AUGUST 2010- JANURAY 2018
Teacher Ierp Poidencia Colombia secondary English and Spanish Full Time (PT) F
Public School
T
JANUARY 2019 MAY2019 Teacher Institucion eductiva Maria auxiliadora Colombia secondary English Full Time (PT) F
Public School
T
Choose OneChoose One F
T
Choose OneChoose One F
T
Choose OneChoose One F
T
Choose OneChoose One F
T
VI. LANGUAGES
Please list all spoken languages and indicate level of fluency.
Languages Spoken Level of Fluency
French Native Fluent Intermediate Beginner
English Native Fluent Intermediate Beginner
Native Fluent Intermediate Beginner
Spanish Native Fluent Intermediate Beginner
Have you ever taken a formal English language proficiency test? Yes No x
a) If yes, please provide the following:
I. Name of test:
II. Date of test:
III. Test score:
b) If no, have you graduated from an English immersion program or English language school?
Yes No x
* If you have not graduated from an English immersion school, you will be required to submit
English language proficiency test scores for application approval.
2
VIII. VISA STATUS AND HISTORY
Do you currently hold a U.S. visa? Yes No x If yes, when does it expire?
mm/ dd / yyyy
Which category? Please briefly explain:
Have you ever held a U.S. visa in the past? Yes No x If yes, when? -
mm/dd/yyyy mm/dd/yyyy
Which category? Please briefly explain:
Have you ever been denied a U.S. visa? Yes No x If yes, when?
mm/ dd / yyyy
Which category? Please briefly explain:
Has anyone filed a petition on your behalf for residency in the U.S.? Yes No x
If yes, when? Please briefly explain:
mm/ dd / yyyy
IX. EMERGENCY CONTACT INFORMATION
Please provide the contact information of an immediate family member. Amity will only contact
this person in case of an emergency.
Juan Zapata
First and Last Name:
Relationship (i.e. Mother): Brother Email:
Phone Number (include country code):
San Judas
Street Address:
Quibdo Choco
City: Province:
Colombia
Country: Postal Code:
3
X. APPLICATION QUESTIONS
Amity would like to get to know more about you. Please answer the following questions.
1. Why are you interested in applying to the Amity Exchange Teacher Program?
2. What do you hope to learn and experience during your time in the United States?
3. As an Amity Teacher, you will be required to share your country's culture.
What ideas do you have to do this?
✔ I certify that the information submitted in this application is true and correct to the best of my knowledge.
I further understand that any false statements may result in denial or termination of Amity’s sponsorship.
SUBMIT
