Study of the United States Institute (SUSI):

SUSI Global Student Leaders on Economic Empowerment Application

1- Full name (exactly as it appears on your passport)

Last Name: Sadraoui

First Name : Roua
Middle Name:

2- Gender
Male
Female

3- Date of birth: 04/19/2001

4- City and country of birth: Gafsa , Tunisia

5- Citizenship

Primary: Gafsa Secondary (if applicable):________________________

6- Country of residence: Gafsa

7- Contact information

Address (street, city, country):_________________________________________

_________________________________________________________________
Home number:_____________________________________________________
Mobile number:_____________________________________________________
E-mail address:_____________________________________________________
Emergency contact name and relationship:_______________________________
Emergency contact mobile number and email:_____________________________

8- Medical, physical, dietary, or other personal considerations: Please describe any pre-existing
medical conditions or disabilities, including any prescription medication you may be taking, or other
dietary/personal considerations. This will not affect the candidate selection process, but will enable the
host institution to make necessary accommodations.

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

9- Academic information

Major: __________________________________________
 Year or credits completed: __________________________________________

Year in school: __________________________________________

University: __________________________________________

Expected graduation date: __________________________________________

10- Work and volunteer experience

_____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

11- Memberships in associations, clubs, etc. (including dates)

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

12- Previous experience in the United States

From: _____________________ (month/day year) To: ___________________ (month/day year)

Purpose:____________________________________________________________________

13- Family residing in the United States

___________________________________________________________________________

14- How did you learn about this program?

___________________________________________________________________________

15- Personal statement: In 250 words or less, please tell us why you are interested in participating in this
program, what you expect to gain from this experience, and what you will contribute to the program. In
addition, your personal statement should provide relevant information on your background, interests,
and/or goals.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
 ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

16- Please check this box if you agree to the following statement .

The information in this application is accurate and complete. The written work in the short essays is my
own and I have not been assisted by any other person. I understand that I may be required to verify
information in this application by providing documentation including (but not limited to) transcripts, test
scores, and writing samples. I also understand that intentionally falsifying information in this application will
disqualify me from U.S. government exchange programs.

Full name: _____________________________________________________________________

Date: _____________________________________________________________ (month/day/year)