Application Form

Spring 2018 YSEALIAcademic Fellowships Application

  1. Please choose one institute you are applying for:

☐Civic Engagement

☐Environmental Issues

☐Social Entrepreneurship and Economic Development

  1. Applicant’s Basic Information, exactly as it appears in passport:

Last Name:

First Name:

Middle Name:

Gender:

Date of Birth : Click here to enter a date.

Age:

Place of Birth:

Country of Birth:

Citizenship:

Passport Number :

Issued Date:

Expiration Date :

C. Contact Information:

Mobile Number:

Alternate Number :

Email Address:

Emergency Contact Person:

Relationship to you:

Emergency Contact Phone:

His/her email:

D. Medical, Dietary, Disability 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.

E. Current Residency

Address:

City:

Province:

Postal Code:

Country:

F. Education Background:(Please add more table if needed)

Institution name / Dates attended: / Current year (if not graduated) / Major field of study / Degree anddate received*

G. Paid Work Experience, including full time or part time employment:(Please add more table if needed)

Institution name / Position / Brief details about your duties / Dates
MM/YY – MM/YY

H. Most Recent Unpaid internship or volunteer experience: (Please add more if needed)

Institution name / Position / Brief details about your duties / Dates
MM/YY – MM/YY

I. Memberships in Associations, Clubs, etc.,: (Please add more if needed)

Association name / Position / Brief details about your duties / Dates
MM/YY – MM/YY

J. Previous Experience in the United States:

Have you travelled to the U.S. before?

If yes, please indicate the dates and the purpose?

K. Family Residing in the United States:

Do you have close family residing in the U.S.?

If yes, please indicate their names, States they reside in, and their relationship to you?

R. Evidence of English Fluency if any:(e.g. paper-based TOEFL or iBT TOEFL scores, IELTS…)

S. Personal Statement by Candidate:

Please tell us about yourself and your goals including the following: What about your background and/or interests makes you competitive for the YSEALI Academic Institutes? What will you contribute to the YSEALI Fellowship? How do you expect your participation in the Fellowship affecting your community, country, or the ASEAN region? How will the Fellowship affect you personally? Please structure your essay in paragraphs and limit your response to 500 words, or approximately a page, single spaced.

______Please submit these following documents to this email: , deadline: Wednesday, Oct 11th, 2017, 11.59pm.

- Complete Application Form

- Official Academic Transcripts

- University Degree (if graduated)

- Your Passport

**each document should be in PDF file, and name the file with your full name, then what the document is, i.e. “SomsackNouansy Passport”