Study in the United States Summer Institute
Student Leader Application
A. Title of Institute
Social Entrepreneurship
Personal Information:
1.Family Name / First Name
(NOTE: AS IT APPEARS IN HIS/HER PASSPORT.)
2. / 3. / 4.
Date of Birth (MM/DD/YYYY) / City of Birth / Country of Birth
5. / 6.
Country of Residence / Country of Citizenship
7.
Home Address
Cell phone / Home Telephone / E-mail
(NOTE: Please include the telephone code for your city or region.)
8. / Male / Female
9. / Medical, Physical, Dietary or other Personal Considerations:
Academic Major, Institution
10.
Major:
11.
Institution
Address
City
Telephone/Cell phone / Fax
12. / Work and Volunteer Experience:
13.
/ Year in School: (Which year student and specialization) / Y
14. / Memberships in Associations, Clubs, etc: (Please include dates)
15. / U.S. Travel:
Purpose / Date / USG-funded
Yes No
Yes No
Yes No
Yes No
16. 17. / Family Residing in the United States: Please list any immediate family members who are currently residing in the United States, including city and state:
17. / English Proficiency:
Reading: / Excellent / Good / Fair
Writing: / Excellent / Good / Fair
Speaking / Excellent / Good / Fair
18. Personal Statement:
Tell us about yourself and your goals including the following: What about your background and/or interests makes your 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.
Applications without essays will not be considered.
Please email completed applications to:
Application deadline: January 8, 2013
In case of questions, please contact Educational Programs Coordinator, Tea Kuchukhidze (2 27 71 48)