2006-2007 EURASIAN UNDERGRADUATE

Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: 2006-2007 EURASIAN UNDERGRADUATE EXCHANGE PROGRAM APPLICATION A program of the Bureau of Educational and Cultural Affairs, United States Department of State 1. 2. 3. 4. 5. 6. 7. 8. NAME (as written on official documents): (Family Name) (First Name) (Middle/Patronymic) COUNTRY OF CITIZENSHIP: COUNTRY OF LEGAL RESIDENCE: PLACE OF BIRTH: (City or Town) (Country) DATE OF BIRTH: (Month) (Day) (Year) GENDER: Male:  Married Female: CITIZENSHIP OF SPOUSE (if applicable): MARITAL STATUS:  Single In order to respond to required US Government inquiries, please check the box below, on a voluntary basis, if you have the following disabilities:  Hearing Impairment   Learning Disorder  Speech Impairment  Other (specify):  Yes  No Apartment: Postal Index: Country: ) Fax: ( ) Email:  Visual Impairment (Legally Blind)  Orthopedic Impairment 9. CURRENT HOME ADDRESS: Is this a dormitory address? Street/Building Number: City: Region or Oblast: Telephone: ( Cell phone (if applicable): ( )_____________________________________________________________________ PERMANENT HOME ADDRESS (IF DIFFERENT): Street/Building Number: City: Region or Oblast: Telephone: ( ) Fax: ( ) Postal Index: Country: Email: Apartment: Cell phone (if applicable): ( )_____________________________________________________________________ Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005 1 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: 10. CURRENT ACADEMIC INSTITUTION: FACULTY/DEPARTMENT: Street: City: Country: Telephone: ( Postal Index: ) Fax: ( ) 11. NATIVE LANGUAGE CONTACT INFORMATION: Native language is: During the selection process it may be necessary for one of our offices to contact you. To assist our offices in maintaining accurate records, please complete the following section in your native language. Name: (Family Name) (First Name) (Middle/Patronymic) Street/Building Number: City: Country: Current Academic Institution: Dean or Academic Advisor Name: Emergency Contact Name: Emergency Contact Address: Emergency Contact Phone/Fax/Email: 12. PRESENT COURSE YEAR:  First Postal Index: Apartment: Region:___________________________________________ Department: Work Telephone: ( Relationship: ) _______  Second  Third* (*only for students enrolled in 5-year university programs) 13. EXPECTED GRADUATION DATE (month/year): 14. CURRENT SPECIALIZATION / MAJOR IN HOME COUNTRY: ____ 15. PROPOSED FIELD OF STUDY IN THE US: Please indicate one specialization below, which most closely matches your current specialization. Unless otherwise noted, all fields of study are offered for first-, second-, and third-year students. If selected as a finalist, applicants may not change their field of study during the program. Accounting (first year only) Agriculture  American Studies  Business  Computer Science (first-year only) Criminal Justice  Economics (second- and third-year only)  Education (second- and third-year only)  Environmental Management  Hospitality Management (first-year only)  International Relations (second- and third-year only)  Journalism and Mass Communications  Law (first-year only)  Political Science  Psychology (first-year only)  Sociology 16. How did you first learn about the Eurasian Undergraduate Exchange Program? Please check only one. Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005 2 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: Academic Advisor Conference Booth Educational Advising Center Electronic listserv Friend/Colleague IATP site Internet AIER offic e Lecture/Presentation Newspaper/Advertisement Program Alumni Radio Television University faculty/staff US Embassy Other: (please specify) 17. Are you applying to any other sponsored educational exchange program for the 2006-2007 academic year?  Yes No   If yes, please specify program:  Name of sponsoring organization: 18. Have you previously traveled on a US Government sponsored or other US exchange program?  No IF YES, PLEASE LIST PROGRAM NAME, YEARS AND US LOCATION:  Yes HAVE YOU EVER RECEIVED A U.S. J-1 VISA?  Yes  No If yes, please list exact dates of visa (month/day/year – month/day/year): HAVE YOU EVER RECEIVED A U.S. F-1 VISA?  Yes  No If yes, please list exact dates of visa (month/day/year – month/day/year): 19. TESTING: If you have not taken the Test of English as a Foreign Language (TOEFL) and are selected as a finalist or alternate, you will be required to take the official TOEFL exam. The cost of this examination will be covered. If you have previously taken the official TOEFL exam, please give your score and the date and place where you took the examination. If selected, you will be required to request that ETS submit an official TOEFL report. TOEFL Score: __________________ Date: __________________ Location: __________________ 20. EXTRA-CURRICULAR ACTIVITIES: Please list all volunteer positions, work experience, awards and leadership positions you have held within the past four years. 21. List below in English all current university courses followed by your past courses with grades you received for th them. First year students should list their current university courses followed by their 11 form courses and final grades. (Attach additional pages if necessary.) Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005 3 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: Describe grading system used (example: “5” = excellent to “1” = failing, “A” = excellent to “F” = failing): ACADEMIC YEAR (for example 2005-2006) SUBJECT / COURSE (class title or “kursovaya rabota”) GRADE 22. PERSONAL STATEMENT A: Please attach a personal statement in English of no more than 1200 words or two pages addressing the following question. Applications are free of charge and may be duplicated Deadline: 5:00 PM, Thursday, December 1, 2005 4 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: Statement A: How do you plan to implement both professionally and personally the experience you will gain with a year of study in the United States? Applications are free of charge and may be duplicated Deadline: 5:00 PM, Thursday, December 1, 2005 5 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: 23. PERSONAL STATEMENT B: Please attach a personal statement in English of no more than 1200 words or two pages addressing the following question. Statement B: Using one or more examples, please discuss your leadership skills and how you plan to use these skills while living and studying in the United States. Applications are free of charge and may be duplicated Deadline: 5:00 PM, Thursday, December 1, 2005 6 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: 24. PERSONAL STATEMENT C: Please attach a personal statement in English of no more than 1200 words or two pages addressing the following question. Statement C: Please write a letter of introduction to your future American roommate or host family. Please describe yourself, your likes and dislikes, hobbies/interests, family life, your most significant experience, etc. Applications are free of charge and may be duplicated Deadline: 5:00 PM, Thursday, December 1, 2005 7 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: Privacy Policy Statement and Application Certification Your privacy is important. That is why we request that all applicants read the following privacy policy statement carefully. 1. Applicant and Participant Information Content and Storage Information about program applicants and current and past participants consists of data contained in their applications, information derived from interviews, and information gathered during the course of their program and as program alumni. This information is stored in written and electronic form indefinitely. Some data, such as contact information and professional experience, is continually updated. 2. Use of Information Information, which is described above, may be: A. B. C. D. Used by selection committees and interviewers to review applicants; Supplied to the program’s funding organization; Submitted to potential host schools, universities, or organizations and/or organizations that provide internship opportunities; Used for the evaluation of an individual’s participation in the program and in the collection of data for general program evaluation, funding agencies or other organizations contracted to conduct evaluations; E. Used for notifying program participants/alumni of upcoming events and programs; F. Provided to participants/alumni of this and other US government–sponsored programs for the purpose of fostering alumni networking; G. Provided to non-commercial, nongovernmental organizations for the purposes of promoting professional development among program participants/alumni; and H. Used for general promotional purposes in written or electronic form, including program directories, newsletters, web sites and other promotional materials. If the applicant or current/past participant does not want to be included in points E-H, it is their responsibility to notify their specific program administrator in Washington. Information on program applicants and current/past participants will not be sold. The principles stated herein are binding only to the administering organization of the UGRAD program; other organizations involved in the administration of these programs may adhere to other privacy or similar policies. I certify that I completed this application myself, without assistance, that the information given in this application is complete and accurate and that I further certify that I fulfill all of the eligibility requirements as stated in the application instructions. I have carefully read and understand all notes and disclaimers provided therein. I understand that the UGRAD program staff reserves the right to verify all the information listed in the application. I understand that giving false or misleading information in the application will result in exclusion from the competition or immediate dismissal from the Eurasian Undergraduate Exchange Program. Signature of applicant Date Applications are free of charge and may be duplicated Deadline: 5:00 PM, Thursday, December 1, 2005 8 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: Eurasian Undergraduate Exchange Program Reference Form #1 (TO BE COMPLETED BY APPLICANT): Name of Applicant_________________________________________________________________ Country_________________________________________________________________________ Name of Evaluator/Reference________________________________________________________ Title of Evaluator__________________________________________________________________ Work Institution___________________________________________________________________ Work Address of Evaluator__________________________________________________________ Work Telephone of Evaluator Fax _________________________ E-mail __________ This reference form may be completed by a supervisor at work, a professor/academic advisor/dean, or a community leader who knows the applicant well and is familiar with the applicant’s academic and/or professional work. Relatives and friends of the applicant may not complete this recommendation form. This form should be typewritten in English, if possible. If not in English, an accurate translation (which may be done by the applicant) must be attached. All recommendations must be signed and stamped. (TO BE COMPLETED BY EVALUATOR): 1 2 How long have you known the applicant? In what capacity have you known the applicant? Check all that apply.  Teacher/Professor  Other (please specify) 3  Job Supervisor  Academic Advisor Please evaluate the applicant as compared to other students in terms of the characteristics below: Excellent Good Fair Poor Unable to Judge  Leadership Potential       Initiative and Problem Solving Skills       Creative and Independent Thinking       Adaptability       Interpersonal Skills       Respect for Others/Responsibility       Interest in Community Service       Maturity      4 Please choose one of the following: Recommend with confidence Recommend Recommend with reservation Do not recommend Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: 5 EVALUATION Please submit short statements in the space provided, giving a candid evaluation of the applicant’s past academic and/or work performance. Your statements will be given careful consideration by the selection committee and American universities and colleges reviewing this application. Therefore, your comments should be as complete and detailed as possible (attach additional pages if necessary). 1. Applicant’s ability to express his/her ideas clearly both in writing and verbally. 2. Applicant’s ability to interact well with other students and professors. 3. Applicant’s strengths and weaknesses as a potential exchange student. 4. Applicant’s outstanding or distinguishing talents and characteristics. 5. Applicant’s potential to significantly contribute to the public sector in his/her home community. I hereby confirm that the answers on this form are my own and represent my professional opinion of the applicant. Signature of Evaluator Date Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: Eurasian Undergraduate Exchange Program Reference Form #2 (TO BE COMPLETED BY APPLICANT): Name of Applicant_________________________________________________________________________ Country_________________________________________________________________________________ Name of Evaluator/Reference________________________________________________________________ Title of Evaluator__________________________________________________________________________ Work Institution___________________________________________________________________________ Work Address of Evaluator__________________________________________________________________ Work Telephone of Evaluator Fax _________________________ E-mail __________ This reference form may be completed by a supervisor at work, a professor/academic advisor/dean, or a community leader who knows the applicant well and is familiar with the applicant’s academic and/or professional work. Relatives and friends of the applicant may not complete this recommendation form. This form should be typewritten in English, if possible. If not in English, an accurate translation (which may be done by the applicant) must be attached. All recommendations must be signed and stamped. (TO BE COMPLETED BY EVALUATOR): 1 2 How long have you known the applicant? In what capacity have you known the applicant? Check all that apply.  Teacher/Professor  Other (please specify) 3 below: to Judge          Job Supervisor  Academic Advisor Please evaluate the applicant as compared to other students in terms of the characteristics Excellent Leadership Potential Initiative and Problem Solving Skills Creative and Independent Thinking Adaptability Interpersonal Skills Respect for Others/Responsibility Interest in Community Service Maturity         Good         Fair         Poor         Unable         4 Please choose one of the following: Recommend with confidence Recommend Recommend with reservation Do not recommend Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005 Application Number ________________ 2006-2007 Eurasian Undergraduate Exchange Program Name: Country of Citizenship: 5 EVALUATION Please submit short statements in the space provided, giving a candid evaluation of the applicant’s past academic and/or work performance. Your statements will be given careful consideration by the selection committee and American universities and colleges reviewing this application. Therefore, your comments should be as complete and detailed as possible (attach additional pages if necessary). 1. Applicant’s ability to express his/her ideas clearly both in writing and verbally. 2. Applicant’s ability to interact well with other students and professors. 3. Applicant’s strengths and weaknesses as a potential exchange student. 4. Applicant’s outstanding or distinguishing talents and characteristics. 5. Applicant’s potential to significantly contribute to the public sector in his/her home community. I hereby confirm that the answers on this form are my own and represent my professional opinion of the applicant. Signature of Evaluator Date Applications are free of charge and may be duplicated Deadline for Citizens of Belarus: 5:00 PM, Thursday, December 1, 2005