APPLICATION FOR THE

2014 GLOBAL UNDERGRADUATE EXCHANGE PROGRAM (GLOBAL UGRAD)

APPLICATION DEADLINE: [5 PM Nove !e" 25# 201$%

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A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State Please provide all answers in English. Please use a paper/ inder clip to hold application materials together. Do not staple.

NAME Please print your name clearly e5(.*16 as it appears on your passport.
!ast "irst #iddle

Please indicate any other spelling(s) or name(s) you use: _____________________________________________ HOME COUNTR7 CONTACT INFORMATION Permanent mailing address in your home country: Street: _________________________________________ Mailing: (if different, e.g. PO Box) __________________ ity: __________________________________________ ountry: _______________________________________

Please affix two photocopies of a Passport-size (2 x 2 inches) photograph here. Please use photocopies, not original pictures.

!"mail address: ___________________________________________ #ome telephone: __________________________ I) 6o," 2*"ee* (--"e22 (e3'3 200 Mo$ile telephone: 6o," (/1/0' (--"e22 (e3'3 PO Bo5)# &1e(2e &"ov/-e !o*+3

e*e"2 )"o 8) /2 -/))e"e0* )"o

PER4ONAL DATA AND PA44PORT MATERIAL4 Sex: Male %emale &ate of Birth:
#onth/Da$/%ear

Place:
Cit$ Countr$

ountry of permanent legal residence: __________________________ ountry of citi'enship: P1e(2e &"ov/-e ( .1e(" &+o*o.o&6 o) *+e &+o*o9-(*( /0)o &('e o) 6o," .,""e0* P(22&o"*3

EMERGENC7 CONTACT INFORMATION Please pro(ide the names and contact information of indi(iduals )ho should $e notified in case of an emergency. *n the +nited States :
&ame 'elationship to $ou Street Address

Cit$

State

()P Code

*elephone &um er

E+mail address

*n your home country:

Cit$

State and/or Countr$

*elephone &um er

E+mail address

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G1o!(1 U0-e"'"(-,(*e E5.+(0'e P"o'"(

(G1o!(1 UGRAD) 2014 A&&1/.(*/o0 Fo"

A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State

NAME (Please print your name here):

FIELD OF 4TUD7 -cademic [Link]: Other %ields of -cademic *nterests: *f selected to participate in the /lo$al +/0-& Program, )hat courses )ould you li1e to ta1e in your [Link] field of study2

3hat courses )ould you li1e to ta1e outside your [Link] field of study2

*f you are currently enrolled as a uni(ersity student, name your uni(ersity: #o) many full academic years of uni(ersity study you ha(e completed (please chec1 one $elo)): , year 4 years 5 years Other ______________________________________

6our academic calendar (e.g. March 47,4 8 &ecem$er 47,4, -ugust 47,4 8 May 47,5)2______________________________________

REFERENCE49RECOMMENDATION LETTER4 Please identify the three (5) indi(iduals )ho )ill $e )riting letters of recommendation on your $ehalf. -t least one should $e from your current institution. Ma1e sure these are people )ho 1no) your academic and personal 9ualities )ell. ,. :ame: Mailing address: ;elephone num$er: 4. :ame: Mailing address: ;elephone num$er: 5. :ame: Mailing address: ;elephone num$er: !"mail address: !"mail address: ;itle: !"mail address: ;itle: ;itle:

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G1o!(1 U0-e"'"(-,(*e E5.+(0'e P"o'"(

(G1o!(1 UGRAD) 2014 A&&1/.(*/o0 Fo"

A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State

NAME (Please print your name here):

PRE:IOU4 ACADEMIC 4CHOLAR4HIP4 Please indicate any scholarships, academic a)ards or honors that you ha(e recei(ed and the year recei(ed:

EDUCATIONAL BAC;GROUND Please pro(ide complete information a$out all the educational institutions that you ha(e attended and, if applica$le, information a$out the institution(s) at )hich you are presently enrolled. 7o, ,2* (**(.+ o))/./(1 *"(02."/&*2 )o" ,0-e"'"(-,(*e 2*,-6 (</*+ E0'1/2+ T"(021(*/o02) (0- o))/./(1 "e2,1*2 o) *+e 'e0e"(1 2e.o0-("6 2.+oo1 1e(v/0' e5( 3 I02*/*,*/o0 N( e (No (!!"ev/(*/o02) Primary School: I02*/*,*/o0 Lo.(*/o0 (C/*6# Co,0*"6) D(*e2 A**e0-eMM977 = MM977 %rom: ;o: M(>o" F/e1o) 4*,-6 De'"ee Re.e/ve(0- D(*e Re.e/ve-? G"(-e Po/0* Ave"('e??

Secondary School:

%rom:

;o:

Post"Secondary !ducation: (+ni(ersity)

%rom:

;o:

< Please identify the name of your degree $y the )ord used at the institution that a)arded you the degree. &o not pro(ide the name of the +.S. educational system=s e9ui(alent. *f you ha(e not yet recei(ed the degree, please indicate the date (month and year) you expect to recei(e it. << Please indicate your /rade Point -(erage (/P-) according to the system used at the institution at )hich you studied. &o not con(ert your /P- to the +.S. educational system=s e9ui(alent. Please explain any gaps in your education:

#a(e you e(er $een dismissed from a school or uni(ersity2

:o

6es

*f yes, please explain )hy2:

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G1o!(1 U0-e"'"(-,(*e E5.+(0'e P"o'"(

(G1o!(1 UGRAD) 2014 A&&1/.(*/o0 Fo"

A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State

NAME (Please print your name here):

LANGUAGE PROFICIENC7 :ati(e language(s): :um$er of years of !nglish study: _____________________ 3here studied: >no)ledge of foreign languages, including !nglish (0ate your a$ilities as !xcellent, /ood, or %air):
L(0',('e N( e Re(-/0' A!/1/*6 @"/*/0' A!/1/*6 4&e(A/0' A!/1/*6

4TANDARDIBED ENGLI4H TE4T 4CORE4 *f you ha(e a ;O!%?@, *;P, or other standardi'ed !nglish test score, please report it $elo). -lso please include a copy of the official score report or other documentation authenticating the score.
Te2* N( e D(*e *(Ae0 o" *o !e *(Ae0 4.o"e

;O!%?@ *;P O;#!0

NONCACADEMIC ACTI:ITIE4 Please list other community ser(ice, internshipsA.o$s, sports or cultural acti(ities in )hich you ha(e participated regularly in the past t)o years. *f you )ere a team leader, council mem$er or other officer in any institution or acti(ity, please note that as )ell.
Lo.(*/o09I02*/*,*/o0 (0- Co0*(.* T6&e o) A.*/v/*6 D(*e2 o) P("*/./&(*/o0 MM977 = MM977

%rom:

;o:

%rom:

;o:

%rom:

;o:

%rom:

;o:

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G1o!(1 U0-e"'"(-,(*e E5.+(0'e P"o'"(

(G1o!(1 UGRAD) 2014 A&&1/.(*/o0 Fo"

A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State

NAME (Please print your name here):

PH74ICAL CHALLENGE49DI4ABILITIE4 Please descri$e any physical disa$ilities you might ha(e. *f you re9uire any special e9uipment or medical treatment as a result of the physical disa$ilities, please descri$e it. ;his information is gathered for statistical purposes and to ensure appropriate placement. ;he /lo$al +/0-& Program does not discriminate on the $asis of race, color, religion, sex, national origin, andAor physical disa$ilities.

FAMIL7 BAC;GROUND Please complete the follo)ing regarding your family: %ather=s :ame: Occupation: #ighest le(el of education attained: :one :um$er of primary school years_____ Bachelor &egree !mployed 0etired ___________6ear !mployer: :um$er of secondary school years_____ Master &egree Ph.&. &eceased ___________ 6ear

Secondary &iploma %ather=s !mployment:

Mother=s :ame: Occupation: #ighest le(el of education attained: :one :um$er of primary school years_____ Bachelor &egree !mployed 0etired ___________6ear :um$er of secondary school years_____ Master &egree Ph.&. &eceased ___________ 6ear !mployer:

Secondary &iploma Mother=s !mployment:

:um$er of si$lings in your immediate family: :um$er of Brothers:

:um$er of Sisters:

Ho< -/- 6o, )/0- o,* (!o,* *+e G1o!(1 UGRAD P"o'"( D Please chec1 all that apply. ;he -merican !m$assy -d(ising Office or other !m$assy contact %rom a friend %rom a relati(e ;he %ul$right ommission %rom a teacher or professor

%rom an ad(ertisement or notice ,Please specif$ the location-: Other ,Please specif$ how-: "C"

G1o!(1 U0-e"'"(-,(*e E5.+(0'e P"o'"(

(G1o!(1 UGRAD) 2014 A&&1/.(*/o0 Fo"

A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State

E44A74: *f you are completing a computer application, please insert your essay responses $elo) the appropriate essay 9uestion. *f you are completing a paper application, please type your essay responses on separate sheets of paper and attach them to your application. E44A7 1: Pe"2o0(1 4*(*e e0*E$50 = 500 <o"-2# *6&e-3 Please descri$e yourself and )rite a clear and detailed description of your academic o$.ecti(es and the reasons )hy you )ish to pursue them in the +S-. &iscuss your goals $oth in terms of your field of study and your o)n personal de(elopment. &escri$e the type of program you )ish to pursue in the +S- and ho) it relates to your academic $ac1ground and interests and your o$.ecti(es for the future. ;he essay is an essential part of the selection process and of your application for placement into an appropriate program. Be sure to include any details that highlight your personality and indi(iduality. E44A7 2: E5.+(0'e P"e&("e-0e22=250 = $50 <o"-2# *6&e-3 3hat are your expectations for the +/0-& program2 3hat are your greatest goals for and fears a$out li(ing in the +nited States2 #o) )ill your personal characteristics help you achie(e andAor com$at these expectations2 E44A7 $: P1e(2e 2e1e.* (0- (02<e" one o) *+e *+"ee F,e2*/o02 !e1o< = 250 = $50 <o"-2# *6&e-3 a. $. c. 3hat can contri$ute to this program, uni(ersity life in the +nited States, and to your community after you return2 *n your opinion )hat is the greatest challenge that your generation )ill face2 3hat ideas do you ha(e for dealing )ith this issue2 #o) do you thin1 community ser(ice $enefits local communities2 Please descri$e any experience you ha(e (olunteering.

PLACEMENT INFORMATION: ;he follo)ing information )ill not $e considered in the e(aluation of your application. *t )ill only assist in the uni(ersity placement process should you $e selected for the +/0-& program. &o you smo1e2 :o 6es -re you )illing to li(e )ith a roommate )ho smo1es2 3hat time do you prefer to )a1e up2 :o 6es

3hat time do you prefer to go to $ed2

#o) )ould you descri$e your preferred li(ing en(ironment (organi'ed, 9uiet, li(ely, clean, cluttered, etc.)2

#o) )ould you descri$e your preferred study en(ironment (silent, loud, little noise, does not matter, etc)2

-re you )illing to li(e on a co"ed floor (a floor that includes $oth men and )omen) or do you prefer a single"gender floor2

3hat uni(ersity clu$s or extracurricular acti(ities )ould you li1e to participate in )hile in the +nited States2

&o you ha(e any allergies2

:o

6es :o

*f yes, please list them: 6es *f yes, please descri$e: :o "D" 6es

&o you ha(e any dietary restrictions2

#a(e you e(er $een con(icted of a felony or other crime2

G1o!(1 U0-e"'"(-,(*e E5.+(0'e P"o'"(

(G1o!(1 UGRAD) 2014 A&&1/.(*/o0 Fo"

A program of the Bureau of Educational and Cultural Affairs, U.S. Department of State #a(e you e(er tra(elled to the +nited States2 *f so, please descri$e the dates, location, and reason for tra(el.

GRANT 4U4PEN4ION9TERMINATION9RE:OCATION
A grant ma$ e [Link], terminated, or suspended. /rounds for revocation or termination include, ut are not limited to0 ,1- violation of an$ law of the United States or the host countr$2 ,3- an$ act [Link]$ to give offense to the host countr$2 ,4- failure to o serve satisfactor$ academic or professional standards2 ,5- ph$sical or mental incapacitation2 ,6- engaging in an$ unauthori7ed income+producing activit$2 ,8- failure to compl$ with the grant9s terms and conditions2 ,:- material misrepresentation made $ an$ grantee in the application form or grant document. A grant ma$ e suspended if0 ,1- the grantee ceases to carr$ out the pro;ect or academic program during the grant period2 ,3- the grantee leaves the host countr$ without authori7ation of the Commission/post or supervising agenc$2 ,4- conditions in the host countr$ re<uire the departure of the grantee for reasons of personal safet$ or securit$.

4IGNATURE By my signature, * certify that, to the $est of my 1no)ledge, the information pro(ided in my application is accurate and complete, and that * intend to return to my home country upon completion of my studies in the +nited States. * also authori'e any school or uni(ersity )hich * ha(e attended or )ill attend to release my transcripts and any report to the designated placement agency. Signature: &ate:______________________________________

CHEC;LI4T FOR COMPLETE APPLICATION DO44IER: Before su$mitting your application to the address on the front page, please $e sure you ha(e included all of the follo)ing 0!E+*0!& components: ___ ompleted, signed /lo$al +ndergraduate !xchange Program application form. ___Personal statement in !nglish, 5C7"C77 )ords, typed.< ___*f you ha(e a passport, please su$mit a copy of the dataAphoto page. ___Official transcripts for years of uni(ersity study ()ith !nglish translations). Please pro(ide grade e9ui(alences to +.S. +ni(ersity grading system.< ___Official results of the national general secondary school lea(ing exam.< ___;hree letters of recommendation from teachersAprofessors, including one from the candidate=s secondary le(el institution ()ith !nglish translations).< ___;O!%?, *;P, or other standardi'ed !nglish test score report, minimum BC7, C77 or higher preferred. ___;)o photocopies of passport"si'e photo. <-ll documents should $e su$mitted in plain, letter"si'ed (F G x ,, inch) paper.

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