2018U.S. Department of State “Sport for Community”

Global Sports Mentoring Program

Application Checklist

Name
Date of Birth (Age)
Gender
Governorate
Previous travel to the U.S.? If yes, please specify duration and type of visit
Egyptian Citizen / Yes
No
Number of Years of Work Experience
Current Employer
Level of Education (Bachelors, Masters, PhD, or other degree)

In order for your application to be complete, please make sure you have:

Completed application checklist form (this page)

Completed application form (pages 2- 6 of this document)

Copy of passport

Most recent curriculum vitae

One or two recommendation letter(s)

Completed applications and required attachments must be received via e-mail by

November 5, 2017 at 4:30 p.m. Any applications received after this time will not be considered. Please e-mail all applications and supporting documents to:

“Sport for Community” Global Sports Mentoring Program

Application Form 2018

  • Name: ______

(First name) (Middle name) (Last name)

  • City and Country of Birth:
  • Passport no:

Date of issuance: ______

(Month/Day/Year)

Date of expiration: ______

(Month/Day/Year)

  • Citizenship:
  • Special considerations, such as allergies, medical and physical challenges, dietary preferences:
  • Business address, telephone and fax numbers:
  • E-mail address:
  • Home address and telephone:
  • Preferred Mailing Address: Business ( ) Home ( )
  • Languages:
  • Native Language:
  • English Proficiency:
  • Speaking:
  • Comprehension:
  • Written:
  • Social Media:If available, please provide information on any social media tools that you may use. These include Twitter, Facebook personal account, Facebook organization account, or other.
  • Present Position: (exact title, starting date, and brief description of role in company/organization)
  • Full Name of Company/Organization:
  • Brief Description of Company/Institution: (Please Include information on the organization's sector (private, public, non-governmental), number of employees, organization mission, relevance to people with disabilities through sports, and website)
  • Professional memberships in local, national or international professional organizations or associations or clubs:
  • Previous travel to the United States: (Please note if you have ever traveled on

a U.S. government program)

  • Dates:
  • Places Visited:
  • Sponsorship/Purpose of Visit:
  • Other Travel Abroad
  • Dates:
  • City and Country:
  • Principal Purpose of Visit:
  • Dates:
  • City and Country:
  • Principal Purpose of Visit:
  • Dates:
  • City and Country:
  • Principal Purpose of Visit:
  • Educational Background: (List highest degree first. Include significant training programs)
  • Dates:
  • Degree/Certificate:
  • Institutions:
  • Field of Specialization:
  • Other Interests and endeavors outside of work: (Hobbies, Volunteer Activities, etc.)

PERSONAL STATEMENT

Please answer all of the following questions in your personal statement: This can be more than one page, but it is important that all sixquestions are answered in the following order.
1-Why do you think you will be a good fit for this exchange program?
2-What do you hope to gain from the mentorshipexperience and how will you maximize the opportunity?
3-What are your accomplishments and contributions to society, particularly in the context of sports and empowerment for people with disabilities?
4-What are your personal, executive, and technical strengths?
5-How do you expect the program to impact your work when you return to Egypt?

REFERENCES

Identify one individual (or more) who can provide you a letter of recommendation (other than the one to be submitted with the application). Please have this/these recommendation(s) letter ready with you if you are called back for an interview.

Name
Title
Mailing Address
Telephone Number
Email Address
Name
Title
Mailing Address
Telephone Number
Email Address

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