"BUILDING GRASSROOTS DEMOCRACY IN MINORITY COMMUNITIES”
An Exchange Program for Bulgaria, Hungary, Romania, Slovakia
and the United States of America
Funded by the U.S. State Department Bureau of Education and Cultural Affairs,
Organized by the Great Lakes Consortium for International Training and Development
in collaboration with Creating Effective Grassroots Alternatives Foundation (C.E.G.A) in Bulgaria, Civil College Foundation (CCF) in Hungary, The Resource Center for Public Participation (CeRe) in Romania, and Center for Community Organizing (CKO) in Slovakia
U.S. Application Form
My organization and myself are interested in participating in this exchange:
1/ We will host 2-3 European fellows for a 3-week internship program.
Time preference:
- April/May 2013- October/November 2013
2/ If we are selected to participate as a mentor, I am available to travel to Europe for a 3-week visit. (As mentor you will asked to host the fellows before you travel to Europe)
Time preference:
- June/July 2013- February/March 2014
The name of my organization:
My name as a mentor:
My E-mail:
My Facebook name:
My Skype name:
The ………………../city…………../state………….. where my organization is located in the U.S.A?
I. Information about the Applicant:
Full name as it is in your passport (you need to have a valid passport in order to be considered by the Selection Committee):
Male/Female:
Citizenship:
(You must have American Citizenship to participate as a U.S. mentor)
Date of Birth (month/day/year):
Mailing address (home):
Phone:Fax:E-mail:
Facebook name: Skype name:
Educational background (including any continuing education or training experience):
If you have higher education, please list what university you attended and what program?
Employment history:
Current employment (job title and major responsibilities):
Experience with minority programs:
Do you have any experience teaching/training others? If yes, what topics?
Do you have experience in writing training materials: If yes, what topics?
Foreign language skills:
(It is not required to speak a foreign language)
Do you have a valid passport? If yes, what is the expiration date?
International travel experience within the last three years:
Have you visited Hungary, Romania, Slovakia, or Bulgaria before? If so, when and what was the purpose of the visit?
II. Information about the Applicant's Organization
Name of the Organization that you want to act as a hosting organization for this exchange (even if you are not working there full time):
When was this organization started?
Please describe your organization and its major activities; please highlight activities that this organization is doing in minority communities:
Organization Address:
Organization Phone: Fax: E-mail:
Web-page:Facebook page:
What is your role, position, current activity in this organization?
When did you start to working in (or support) this organization?
Please share some information about the community where your organization is located:
The total number of people employed:
Are there any volunteers of this organization: (if yes how many):
How big is the population that your organization serves?
How many of them belong to a minority population?
What are the minorities and their ratio in your community you serve? Please list them:
What are the most successful programs or services that your organization provides?
Do you or your organization have any international collaboration experience?
If yes, please explain:
Attachments:
- Please write an essay about any of your success story on how your organization is working with minority populations (No more than 2 typed pages, single spaced)
(Please be ready to provide additional information on this later if you are selected)
2. Scanned copy of your passport bio pages (with your photo and date of birth on it)
DATE:______
SIGNATURE and contact information of the leader of the organization who is willing to provide an internship:
______
______
Your signature : ______
Thank you for filling out the Application Form.
Deadline for emailing your application: December 15, 2012
Please send one electronic application by E-mail with the scanned attachments to
Juli Bertalan, GLC Internship Coordinator at
and please copy to:
Dr. Elizabeth Balint, GLC Project Manager in Toledo, OH USA
For any questions you can contact Juli Bertalan at 724-689-9185 and/or
Elizabeth Balint at 419-973-8007.
THANK YOU!