YSEALI Academic Fellowships Application

Incomplete applications will not be considered.

A. Applicants Full Name, exactly as it appears in passport:

Prefix:

Choose an item.

Last Name

First Name

Middle Name

B. Gender

:
Male

C. Date of Birth

D. Place of Birth

Female

E. Country of Birth:
F. Citizenship
Primary
Secondary

:
:

(if applicable)
G. Current County of Residency

H. Medical, Physical, Dietary or other Personal Considerations:

Disability:
Please describe any pre-existing medical conditions, including any prescription
medication the candidate may be taking, or any other dietary or personal consideration.
This will not affect candidate selection, but will enable the host institution to make any
necessary accommodations.

Nomination Due: Wednesday, December 31, 2014

Questions? Call: (021) 3435-9641; E-mail: YSEALIjkt@state.gov

YSEALI Academic Fellowships Application

Nomination Due: Wednesday, December 31, 2014

Questions? Call: (021) 3435-9641; E-mail: YSEALIjkt@state.gov

YSEALI Academic Fellowships Application

I. Applicant Contact Information:
Address
:
City

Province

Postal Code

Country

Email

:
*if you do not have an active email address, please create one prior to
submitting your application, and indicate it here

Phone

Emergency Contact Phone:

Emergency Contact Name and Relationship:
*Example: John Doe, Father
J. Academic Major, Institution/University:
-Major
:
-Home Institution

Country Name
-Institution/University :
K. Work Experience, including previous positions, titles, institutions, dates of
employment (dd/mm/yyyy), and part/full time position:
From

To

Title/Institution
(Please specify if
position is part time)

Nomination Due: Wednesday, December 31, 2014

Questions? Call: (021) 3435-9641; E-mail: YSEALIjkt@state.gov

YSEALI Academic Fellowships Application

L. Volunteer Experiences :
From

To

Title/Institution

M. Year in School (or Semester in School) and Expected Graduation Date, or date
degree attained if already graduated:
N. Memberships in Associations, Clubs, etc., including position type, title, and
Organization name:
*Please include dates (example: Student Government, May 2011 to June 2012)

O. Previous Experience in the United States:

Have you travelled to the U.S. before?
Yes
No
If yes, please fill out the following section
From:

To:

Purpose:

Nomination Due: Wednesday, December 31, 2014

Questions? Call: (021) 3435-9641; E-mail: YSEALIjkt@state.gov

YSEALI Academic Fellowships Application

Nomination Due: Wednesday, December 31, 2014

Questions? Call: (021) 3435-9641; E-mail: YSEALIjkt@state.gov

YSEALI Academic Fellowships Application

P. Family Residing in the United States:
Do you have close family residing in the U.S.?
Yes

No

If yes, please fill out the following section; if no, please write None.
*Please include city and state (Example: John Doe Chicago, IL)

Q. Evidence of English Fluency:

(Please note if you have taken a language proficiency test, lived abroad, or taken English
language courses. If you have taken any language proficiency test please provide the
date it was taken and your test score if you have taken English language courses please
indicate your level of English in the course.

R. Please check to which institute you are applying (only one may be checked)
Civic engagement
Environment and natural resources management
Entrepreneurship and economic development
S. Personal Statement by Candidate:
Tell us about yourself and your goals including the following: What about your
background and/or interest makes you competitive for this particular institute (please be
as specific as possible)? What will you contribute to the group? How do you expect this
experience will affect your future academic and professional career? How will it affect
you personally?
Please attach your response, limited to 250 words, and submit along with this completed
application and one letter of recommendation from someone who knows you well, to
YSEALIjkt@state.gov.

Nomination Due: Wednesday, December 31, 2014

Questions? Call: (021) 3435-9641; E-mail: YSEALIjkt@state.gov