Vn.usembassy.gov



-3276591339855191125-91439APPLICATION FORMYSEALI ACADEMIC FELLOWSHIPChoose one theme:? Civic Engagement? Social Entrepreneurship and Economic Development? Environmental IssuesFULL NAME: (exactly as it appears on your passport)Last Name(s): First Name(s):Middle Name(s):Gender:Date of Birth (mm/dd/yyyy)City of Birth: (exactly as it appears on your passport)Country of Birth:Country of Citizenship:Country of Residence:Contact Information:Address:Telephone:Cell phone:E-mail:Emergency Contact Name and Relationship:Emergency Contact Phone:Emergency Contact E-mail:Medical, Physical, Dietary or other Personal ConsiderationsPlease state if you have any existing medical conditions or is currently taking any prescription medication. ?This will not affect your selection, but will enable the host institution to make any necessary accommodations.Educational background: (begin with the most recent; add more rows if needed)Institution Name (No abbreviations)Institution Location (City, Country)Dates Attended(MM/YY-MM/YY)Major Field of StudyDegree Received and Date Received**If you have not yet received the degree, please indicate the date (month and year) you expect to receive it.Work Experience (including previous positions and titles; begin with the most recent; add more rows if needed)From – ToMM/YY – MM/YYPosition (Please specify if position is part-time)InstitutionLocation (City, Country)Volunteer, Community service and Extra-Curricular Activities: (begin with the most recent; only include activities you have participated in the last 3 years; add more rows if needed)Location (Institution and Contact)Type of Activity and Your RoleDate of Participation(MM/YY – MM/YY)Active Memberships (in Associations, Clubs, etc.)Previous Experience in the United States: Please list any and all trips the candidate has made to the United States and include approximate dates and the reason for travel.Family Residing in the United States Please list any immediate family members who are currently residing in the United States, including city and state.Evidence of English Fluency, if any (e.g. paper-based TOEFL or iBT TOEFL scores, IELTS…)Name your most significant publications/honors/awards/projects/other accomplishments (no more than 10)Essays (no more than 500 words) Paragraphs, single spaced.Please answer the following questions: What about your background and/or interests makes you competitive for the YSEALI Academic Fellowship? What will you contribute to the Fellowship? How do you expect your participation in the Fellowship will impact your community, country, or the ASEAN region? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download