Application form for FLC 2014

ID PHOTO
35x45mm

Please complete the form below Do not abbreviate Optional fields are marked with an asterisk (*) If you need to provide additional information, attach additional documents to your form NAME
( )

Last: First: Middle/Patronymic: Korean name:

(if applicable)

GENDER
( )

Female

Male

OCCUPATION
( )
(e.g. lawyer, educator, surgeon, politician list only one)

BIRTH INFORMATION
()

Birth Country: Birth date: No.: / / Name:

(birth year/month/day)

City:

PASSPORT Information () YEAR OF IMMIGRATION

()

Nationality:

(Year of immigration from the Korean Peninsula, if applicable.)

Home Country State Province/Region Street address Office Country State Province/Region Street address Home: Office: Mobile: Fax: E-mail: ( ( ( ( ) ) ) ) @ Zip/Postal code City Zip/Postal code City

CURRENT ADDRESS
( )
(check box of preferred mailing address)

CONTACTS
()

Mother tongue: LANGUAGE COMPETENCE

( )

Language Korean English Year(s)

Fluently

Speaking Not fluently

Easily

Understanding Not easily

School/Major

Country/City

Earned degree

EDUCATION
( )

Years (from/to) - pres. CAREER HISTORY

( )
(List in chronological order starting with current position)

Organization

Position
current position

Country/City

*CAREER-RELATED ACTIVITIES
( )
(e.g., consulting, business directorships, advisory boards)

Years (from/to)

Organization

Position

Country/City

*CIVIC, POLITICAL, PHILANTHROPIC ACTIVITIES AND CURRENT MEMBERSHIPS

(, , )

Year

Role

Organization
(do not abbreviate)

Location

*OTHER ACHIEVEMENTS
( )

Year *AWARDS, HONORS, GRANTS

( )

Award

Granting body

Location (if applicable)

*ADDITIONAL INFORMATION
( )
(e.g., professional certifications, military records, affiliations, religious denomination, avocations etc.)

I certify that the statements made by me in the above application form are true, complete and correct to the best of my knowledge and belief.

DATE: 2014/

SIGNATURE

YYYY/MM/DD

Personal Statement

Please include at least one letter of recommendation describing your personal reasons and goals for participating in the Future Leaders Conference 2014. (You might cite specific aspects of the FLC program that you have heard or read about, personal experiences with leadership and Korean community that motivated your participation in the program, or what outcomes you anticipate as a result of your participation.)