2021 STUDY OF THE U.S. INSTITUTE FOR STUDENT LEADERS ON WOMENS LEADERSHIP Application Form Note : Application must be typed and responses must be in English. Answer all questions, if not applicable put N/A. A. Applicant’s Full Name, exactly as it appears on applicant’s passport: First Name: ____________________________________________ Last Name: ____________________________________________ B. Gender: ____________________________________________ C. Date of Birth: ____________________________________________ (MM/DD/YYYY) D. Birth City: ____________________________________________ E. Birth Country: ____________________________________________ F. Citizenship: ____________________________________________ Secondary (if applicable): ________________________________ G. Residency: ____________________________________________ H. Medical, Physical, Dietary, or other Personal Considerations: Disability: __________________________________________________ This will not affect candidate selection, but will enable the host institution to make any necessary accommodations. ___________________________________________________________ ___________________________________________________________ I. Candidate Contact Information: Address: __________________________________________________ City: __________________________________________________ Home State or Province: ______________________________________ 1 | Page
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2021 STUDY OF THE U.S. INSTITUTE FOR STUDENT LEADERS ON
WOMENS LEADERSHIP
Application Form Note: Application must be typed and responses must be in English. Answer all questions, if not applicable put N/A.
A. Applicant’s Full Name, exactly as it appears on applicant’s passport:First Name: ____________________________________________Last Name: ____________________________________________
B. Gender: ____________________________________________
C. Date of Birth: ____________________________________________(MM/DD/YYYY)
D. Birth City: ____________________________________________
E. Birth Country: ____________________________________________
F. Citizenship: ____________________________________________Secondary (if applicable): ________________________________
G. Residency: ____________________________________________
H. Medical, Physical, Dietary, or other Personal Considerations:Disability: __________________________________________________This will not affect candidate selection, but will enable the host institution to make any necessary accommodations. ______________________________________________________________________________________________________________________
I. Candidate Contact Information: Address: __________________________________________________City: __________________________________________________Home State or Province: ______________________________________Postal Code: ____________________________________________Home Country: ____________________________________________Email: ____________________________________________Phone: ____________________________________________
J. Emergency contact information:
Name and Relationship: ______________________________________Address: ____________________________________________Email: ____________________________________________Phone (mobile): ____________________________________________
K. Academic Major, Institution: Major: ____________________________________________Institution: ____________________________________________Home Institution Country Name: ________________________________
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2021 STUDY OF THE U.S. INSTITUTE FOR STUDENT LEADERS ON
WOMENS LEADERSHIP
Application Form Note: Application must be typed and responses must be in English. Answer all questions, if not applicable put N/A.
L. Work and Volunteer Experience: ______________________________________________________________________________________________________________________
M. Year in School: ________________________________Expected Graduation Date: ________________________________
N. Memberships in Associations, Clubs, etc.: *Please list name and dates (Example: Student Government, May 2011 to June 2012)______________________________________________________________________________________________________________________
O. Previous Experience in the United States: *Please list purpose and dates (Example: Travel, July 2017 to August 2017)______________________________________________________________________________________________________________________
P. Family and Friends Residing in the United States:*Please list the name, city, and state (Example: John Doe – Chicago, IL)______________________________________________________________________________________________________________________
Q. Evidence of English Fluency: ________________________________________________________________________________________________________________________________________________________
R. Reference Statement by a Teacher or a Mentor/Contact: After having known the candidate, please tell us about this individual and why you feel that s/he is well suited for this institute. What makes this candidate unique? What, in particular, will this candidate contribute? What distinguishes her/him from the other students who are applying for this program?
Please note that the reference provider cannot be a relative or a family member, and request your reference provider to include full contact information in the reference letter.
S. Candidate's Personal Statement: Tell us about yourself and your goals including the following: What about your background and/or interests makes you competitive for the SUSI exchange program? What will you contribute to the program? How will the program affect you personally or professionally?
Please structure your essay in paragraphs and limit your response to 500 words, or approximately a page, single spaced.
