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2010 United States-Syria Grassroots Diplomacy Program

INSTRUCTIONS: Please fill in the following form completely. When you have
finished, “SAVE AS” and title the document, “LAST NAME, First Initial + FORM,” (i.e. SMITH, J Form). IN ONE E-MAIL, send this completed application form along with Essay A, Essay B, and your resume (optional) to: grassrootsdiplomacy@amln.org.

DEADLINE FOR SUBMISSION: June 11, 2010
A. PERSONAL INFORMATION
LAST NAME:       DATE OF BIRTH (mm/dd/yy):       FIRST NAME:       GENDER: M F SOCIAL SECURITY NO.:    -  -    

(OPTIONAL) ETHNICITY: (Please Type)      

B. CONTACT INFORMATION
CURRENT MAILING ADDRES:       CITY:       PHONE NO.:    -   -    

STATE:       E-MAIL ADDRESS:

ZIP CODE:      

     

CURRENT ADDRESS VALID UNTIL (mm/dd/yy):      

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2010 United States-Syria C. EMERGENCY CONTACT INFORMATION Grassroots Diplomacy Program LAST NAME: FIRST NAME:
            RELATIONSHIP TO STUDENT: WORK PHONE NO.:          -   -     E-MAIL ADDRESS: HOME PHONE NO.:    -   -           ADDRESS:       CELL PHONE NO.:

   -   -    

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2010 United States-Syria Grassroots Diplomacy Program
E. EXTRACURRICULAR ACTIVITIES, JOB EXPERIENCE, HONORS/AWARDS and DATES
In the space below, please BRIEFLY list and describe your extracurricular activities and position/title, job experience, awards or honors you have received, and all corresponding dates. Fill this section out even if you intend to send a resume. 1.       2.       3.       4.       5.       6.       7.       8.       9.       10.       Etc:      

D. EDUCATIONAL BACKGROUND
INSTITUTION ATTENDED :                   DATES ATTENDED (mm/yy) From – To:      -           -           -      DEGREES EXPECTED OR RECEIVED AND DATE (mm/yy): Degree:       Date:       Degree:       Date:       Degree:       Date:       FIELD OF STUDY:

GPA:

Major:      Minor:       Major:      Minor:       Major:      Minor:      

Major:      Cumulative:       Major:      Cumulative:       Major:      Cumulative:      

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2010 United States-Syria Grassroots Diplomacy Program
F. LANGUAGE BACKGROUND
PLEASE GIVE A SELF-APPRAISAL OF YOUR COMPETENCE IN ARABIC (MODERN STANDARD) YEARS OF FORMAL STUDY:       SPEAK: Select COMPREHEND: Select READ: Select WRITE: Select

OTHER LANGUAGES STUDIED:      

LEVEL OF PROFICIENCY: Select

G. RECOMMENDATION INFORMATION
NAME OF RECOMMENDER: INSTITUTION:             TITLE: RELATIONSHIP TO YOU:             Please provide a letter of recommendation from an academic reference. Send this letter in a signed, sealed envelop to: AMERICAN MIDEAST LEADERSHIP NETWORK 2010 UNITED STATES-SYRIA GRASSROOTS DIPLOMACY PROGRAM P. O. BOX 2156 LONG ISLAND CITY, NY 11102

H. ADDITIONAL INSTRUTIONS
Please make sure to arrange for the AMLN to receive an official transcript from your college or university at the above listed mailing address. After you have completed this form, be sure to download and complete Essay A and Essay B, both available on the AMLN Web site. If you have any further questions regarding your application or the program, please contact AMLN President Rami Nusseir at rami@amln.org or at .

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