UNIVERSITY OF NEW YORK/TIRANA

Application Form for First-Year Scholarships

All students applying for scholarships for the 2010-2011 academic year are required to complete
this application form. It must then be submitted along with: 1) two references; 2) copies of a high
school diploma (or the equivalent documents); 3) and a transcript of previous academic work. All
documents must be submitted by September 27, 2010, at 17.00 for consideration.
Personal Information
Name and Surname: __________________________________________ Telephone: ___________
Permanent Home Address: _____________________________________________________________
City/Town: __________________________________ Country: ___________________________
Mailing Address (if different from above): ________________________________________________
City/Town: __________________________________ Country: ___________________________

Date/Place of Birth: ____________________________________________________ Sex: M F

Intended Major(s): _____________________________________________________________________

Educational Background
A. High School Education
High School: ________________________________________ Telephone: __________________
Address: _____________________________________________________________________________
City/Town: __________________________________ Country: ___________________________

Date of Graduation: _________________________ Grade Point Average (1):

Year 1: _____________
Year 2: _____________
Year 3: _____________
Year 4: _____________

Note: No statement of a Grade Point Average will be taken into consideration if not accompanied with the respective
transcript records.
B. Previous College/University Education (to be completed only by students transferring from another
institution or returning to school)
College/University: ______________________________________ Telephone: __________________
City/Town: __________________________________ Country: ___________________________

Date of Graduation: _________________________ Grade Point Average: ________________

Degrees Earned: ____________________________

C. English Language Experience (Please rate your ability on a scale of 1 to 5 with 1 being the
lowest and 5 the highest ability.)
1. What is your level in written English? __________
2. What is your level in spoken English? __________
3. Are you currently enrolled in an English Language Program? _________
If yes, which program? __________________________________________________________
4. Have you earned an English Aptitude Certificate? _____________
If yes, where and when? _________________________________________________________

Work Experience
List any job (including summer employment) you have held during the past three years.
Nature of Work Employer Dates

References
Names and contacts of two individuals submitting reference forms:
Name: ______________________________________________ Telephone: __________________
Name: ______________________________________________ Telephone: __________________

Statement of Agreement
I have read and am in agreement with the terms and conditions of this application process. I hereby
authorize the University of New York/Tirana to determine whether I am qualified to receive a scholarship.
My signature below indicates that all information contained on this form is complete, factual, and honestly
presented.

Applicant’s Signature: _________________________________ Date: _____________