2022 Algerian Youth Leadership Program

Adult Application Signature Page

Please note: Please hand-sign twice below. The actual hand-written signature of the applicant must be below for the
application to be considered complete. Typing your name by computer on the signature line is NOT considered valid.

By signing this form, you are certifying that all of the information on the application is true and correct. If any of the
information in your application is found to be false, you will be disqualified from the program and will not be eligible for
any Department of State or U.S. Embassy exchanges/programs in the future.

ADULT APPLICANT SIGNATURE

By signing this, I indicate that I meet all of the requirements for participation in this program and that all the information
in this application is accurate and true.

Applicant Name ________________________________________

Applicant signature (must be hand-written) ___________________________________________________

Date ____________________

Please check ONE and sign a second time.

 I hereby consent to and authorize the U.S. Embassy in Algiers, the U.S. State Department’s Bureau of
Educational and Cultural Affairs and the Northern Nevada International Center to exhibit, reproduce, distribute,
and/or display my name and image (in printed, digital and video form) in all media and/or technology developed
in connection with the Algerian Youth Leadership Program.
 I do NOT consent to the use of my image or name in connection with the Algerian Youth Leadership Program

Applicant Name ________________________________________

Applicant signature (must be hand-written) ___________________________________________________

Date ____________________