2017Study of U.S. Institutes (SUSI)
Student Leader Nomination Form

A. Title of Institute

Civic Engagement

B. Nominees Full Name, exactly as it appears on candidate's passport

Last Name:

First Name:

Middle Name:

C. Gender

Male

Female

D. Date of Birth

Type mm/dd/yyyy and click on calendar menu to confirm Month, Day, and Year.

E. Birth City

F. Birth Country

G. Country of Citizenship

Primary:

Secondary (if applicable):

H. Country of Residency

I. Medical, Physical, Dietary, or other Personal Considerations

Please describe any pre-existing medical conditions, including any prescription medication the candidate may be taking, or any other dietary or personal consideration. This will not affect candidate selection, but will enable the host institution to make any necessary accommodations.

J. Candidate Contact Information

Address:

City:

Home Province:

Postal Code:

Home Country:

Email:

*If you do not have an active email address, please create one prior to submitting your application and indicate it here.

Phone:

Emergency Contact Phone:

Emergency Contact Name and Relationship: *Example: John Doe, Father

Emergency Contact Email:

K. Academic Major, Institution

Major:

Home Institution Country Name:

Institution:

L. Work and Volunteer Experience

M. Year in School

(E.g., first, second, third, fourth. Candidates must have at least one semester of school remaining at their home school after completing the SUSI program)

N. Memberships in Associations, Clubs, etc.

*Please include dates (Example: Student Government, May 2011 to June 2012)

O. Previous Experience in the United States

From(mm/dd/yyyy) / To (mm/dd/yyyy) / Purpose

P. Family Residing in the United States

*Please include city and state (Example: John Doe -Chicago, IL). Having close family residing in U.S. will not affect nomination.

Q. 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 this particular institute (please be as specific as possible)? What will you contribute to the group? How do you expect this experience will affect your future academic and professional career? How will it affect you personally? Please structure your essay in paragraphs and limit your response to 250 words, or approximately half a page, single spaced.

THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE NOMINATING PARTY ONLY. APPLICANTS SHOULD STOP FILLING OUT THIS FORM HERE.

FOR NOMINATING PARTY ONLY:

R. Evidence of Nominee’s English Fluency

*Evidence may include TOEFL test scores, grades in English courses, or assessment from a native English speaker.

S. Statement by Nominating PartyJustification of Nominee in Institute

This is one of the most important components of the application. After having interviewed 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? Why is this a priority nomination?

Please return completed form to by Friday, September 30, 2016