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YOUNG MUSLIM LEADERS PROGRAM

FY2015 PARTICIPANT BIODATA FORM

All fields should be completed, either by entering text over the grey placeholder text or selecting an option from the dropdown menu as appropriate. Please direct any questions to ; 020 7894 0652). Once completed, please save as a Word doc and return to by November 21, 2014.

PARTICIPANT: Surname, First name Middle name(s)

Names as in Passport

PREVIOUS U.S. TRAVEL

Include purpose of travel (“vacation” or “business”), dates (arrival/departure) and places visited in that order - please put most recent first)

UNIVERSITY, SUBJECT

PREVIOUS PROFESSIONAL EXPERIENCE

Please list dates, position, and organization, with most recent first.

PROFESSIONAL TRAINING

Certificates or courses attended outside of university degree

PREVIOUS EXCHANGE PROGRAMS Give details of previous exchange programs

SPOKEN LANGUAGES List languages spoken and fluency: 1=basic, 5=fluent

PUBLICATIONS

List publications. If not applicable, write “n/a”

PROFESSIONAL MEMBERSHIPSList professional memberships. If not applicable, write “n/a”

SPEAKING REQUESTS If asked to speak informally to small groups, what subjects would nominee speak on?

INTERESTS

Professional:Click here to enter text.

Avocational (hobbies): Click here to enter text.

TRAVEL ABROAD (non-U.S.)

List non-U.S. travel, giving approximate dates, purpose and the places visited - most recent first

CONTACT DETAILS (Preferred: Choose an item.)

Office Address Number, Street, City, County, Postcode

Tel: Telephone number / Mobile:Mobile number
Fax:Fax number / E-mail: Email address

Home Address Number, Street, City, County, Postcode

Tel: Telephone number / Mobile:Mobile number
Fax:Fax number / E-mail: Email address

DATE OF BIRTH Month Day, Year e.g. November 12, 1981

PLACE OF BIRTH Give town/city and country

PASSPORT NUMBER Enter passport number

PLACE OF ISSUEGive city and country

DATE OF ISSUE Month Day, Year e.g. September 19, 2005

DATE OF EXPIRATIONMonth Day, Year e.g. September 19, 2015

MEDICAL, PHYSICAL AND DIETARY CONSIDERATIONS? Choose Yes/No

If applicable, list allergies or food restrictions (halal/vegetarian e.t.c.); or other issues such as fear of flying; if not applicable, write “none”; Smoker Choose Yes/No

Driver Choose Yes/NoIf yes, is nominee willing to drive in the U.S? Choose Yes/No or n/a

MARITAL STATUS: Choose status; Partner’s/Spouse’s Name: Enter name here, or write “n/a”

WOULD YOU LIKE TO BE ADDED TO THE CULTURAL MAILING LIST AND RECEIVE EMAILS FILM SCREENINGS, FOREIGN POLICY AND ARTS EVENTS? Choose Yes/No or n/a

QUESTIONS

  1. What do you think is the greatest threat/challenge to the world at the moment? (150 words)
  1. How would you defeat/surmount that threat/challenge? (150 words)
  1. What is your perception about Islam in America or the American Muslim experience? (150 words)
  1. Do you think hashtags/social media can encourage people to take collective action on issues of importance? How would you/do you use social media to achieve these goals? (150 words)

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PII: Personally Identifiable Information