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2015

THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION

INSTRUCTIONS
Note to applicant: Complete this
form on your computer, save it and
email the completed form to the
address below. Specific instructions
for each form are located at the top of
the form. Email, fax or mail the
completed application to the address
below.
Forms 5 & 6 should be downloaded
separately and emailed to your
referees to be filled out and sent
directly to the Hansen Summer
Institute. Attach an official transcript of
your last two full years of university
study.
APPROXIMATE PROGRAM DATES:
June 29 – July 20, 2015
DUE DATE: RETURN THE COMPLETED
APPLICATION POSTMARKED BY
JANUARY 5, 2015. If you do not return the
completed application by the postmark date,
your application will not be considered.
Email, Fax or Mail your application.
EMAIL application to blamb@sandiego.edu,
FAX application to 619-849-8195
OR MAIL your application to
The Hansen Summer Institute on Leadership
and International Cooperation University of
San Diego
School of Leadership and Education Sciences
5998 Alcala Park
San Diego, California 92110-2492

ELIGIBILITY REQUIREMENTS:

Be under 25 years of age with at least two
(2) years of college/university or a
graduate student in good standing.

Demonstrated commitment to community,
national or international service

Preference will be given to those who
have not visited the the United States
before this 2015 program

An academic advisor must verify, in
writing, your English proficiency. Semifinalists will be required to participate in a
telephone interview.

All materials, essays and other
documentation must be original.
Any quoted sources must be
properly credited.

FORM 1. BIOGRAPHICAL INFORMATION
APPLICANT INFORMATION (write your name as it appears or will appear in your
passport)
Afandi
Amir
Mahmud
Family Name ____________
First Name____________
Middle Name_______
Male

Female

Palembang
______________
Place of Birth

Date of Birth: _____________
Indonesia
________________
Country of Birth

Indonesia
_____________________
Country of Citizenship

Jalan Kolonel H burlian km 7.5, RT 29 RW 10 no 1742 Kecamatan Sukarami, Kelurahan Sukarami
Palembang
_____________________________________________
__________________
Permanent Address
City

Sumatera Selatan
Indonesia
30152
_________________________
________________________
________
Province or State
Country
Postal Code

_______________________
Home Telephone Number

+6289627258103
____________________
Work or Mobile Phone Number

Have you ever been to the United States before?

Yes

No

If yes, for how long? Dates From: _____________ To: _______________
_______________________________________________
Purpose of Visit to the United States
International Airport Sultan Mahmud Baddarudin II
Airport closest to you: ________________________
CURRENT CONTACT INFORMATION
___________________________ _____________________ ______________
Address
City
Postal Code
______________________
__________________________
Province or State
Country
_____________________
_____________________________
Home Telephone Number
Work or Mobile Telephone Number
___________________________________
Email Address
_______________________________________
Best telephone number where you can be reached for purposes of an interview
EMERGENCY CONTACT INFORMATION
____________________________
____________________
Name
Relationship to You
_______________________________________
Address
_____________________
________________
___________
Country
Postal Code
City
___________________________
_______________________
Work or Mobile Telephone Number
Home Telephone Number
UNIVERSITY OR COLLEGE INFORMATION
______________________________________
Name of Institution
_________________________________________
Address
____________________ ________________
_______________
City
Country
Postal Code
_________________________________
Your Faculty or Major

Examples include prizes. how many years have you studied English? _____ Where have you studied English? ________________________________ Additional Languages Spoken: _____________________________________ CURRENT ACADEMIC LEVEL OR YEAR __________________ . ACTIVITIES AND ACHIEVEMENTS SECTION 1 List your activities and interests and indicate how many hours each month you spent on each activity.2015 THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION Applicant Name _____________________________________ FORM 2. volunteering. INTERESTS AND SPORTS _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ HOURS EACH MONTH ______________ ______________ ______________ ______________ ______________ ______________ DATES OF ACTIVITY __________ __________ __________ __________ __________ __________ ACHIEVMENTS. AWARDS AND LEADERSHIP POSITIONS _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ NAME OF INSTITUTION ______________ ______________ ______________ ______________ ______________ ______________ DATE RECEIVED __________ __________ __________ __________ __________ __________ TRAVEL TO OR LIVING OUTSIDE YOUR COUNTRY (Country & City) _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ DATE PURPOSE ______________ ______________ ______________ ______________ ______________ __________ __________ __________ __________ __________ What is your proficiency in English? (Choose from drop down list – excellent. • Sports played. fair or poor) Reading Excellent Good Fair Poor Writing Excellent Good Fair Poor Listening Excellent Good Fair Poor Speaking Excellent Good Fair Poor Is English your native language? Yes No If English is not your native language. and any significant achievements for which you have been recognized. • • Special training or hobbies. • Work experience. You can include: • Clubs and organizations you have joined. during the last three years only. honors. Other activities such as religious or youth groups. social activities. good. SECTION 2 List any awards or prizes you have received. medals or leadership positions SECTION 3 If you have traveled to or lived in any other countries list in this section: ACTIVITIES.

your country and your community? Enter your essay here: . You may only use the allocated space. PERSONAL STATEMENT Answer the following questions.2015 THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION Applicant Name _______________________________ FORM 3. Why you would like to participate in this leadership and international cooperation program? How does conflict among peoples affect your world.

2015 THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION Applicant Name ________________________________________ FORM 4. ON LEADERSHIP Answer the following questions. What aspect of this position was important to you? Why? 4-2 What leadership skills would you bring to this program? 4-3 What does leadership mean to you? 4-4 How will participation in this program enhance your career goals? Enter your essay here: . 4-1 Describe a situation in the past two years when you were in a leadership role. You may only use the allocated space.