Your proposed Field of Study to pursue during the Community College Initiative program (check one):

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1 COMMUNITY COLLEGE INITIATIVE PROGRAM STUDENT APPLICATION DEADLINE: before 20 December 2012 before 5:00 p.m. IMPORTANT: Do not leave blank spaces. If an answer does not apply, please write NA. Please complete your application in English. Personal Information Name of applicant SURNAME Escriba su apellido en MAYUSCULA. FIRST MIDDLE Home Address: Escriba el nombre de la calle, barriada, ciudad o pueblo, provincia. Home Phone: Street and number: City: State/province: Country: Place of birth (city or town and country, as listed in passport, if available): City of birth: Country: Country of citizenship: Gender: Male Female Marital status: Single Married What is the highest educational degree you have completed? Mobile Phone: Date of birth (month/day/year): Month of birth: Day of birth: Year of birth: Do you have a passport? yes no Are you currently a student? yes no If yes, name of college/institution: Have you participated in any U.S. government exchange program? Yes No If yes, program name and year: Your proposed Field of Study to pursue during the Community College Initiative program (check one): Agriculture Applied Engineering Business Management and Administration Early Childhood Education Information Technology Media Tourism and Hospitality Management Within your proposed Field of Study, please describe your specific area of interest and your related experience:

2 2 Knowledge of languages: Rate yourself Excellent, Good, Fair, or Poor. Include all languages that you speak or have studied, including English. List your native language also. Language Reading Writing Speaking Listening Language proficiency If you have taken any standard test of English language proficiency (for example TOEFL, TOEIC, IELTS) please identify the type of test taken, give the results, and provide a copy of the test results. Test Taken: Date Taken: Results (attach copy): Background Information List Educational Institutions Attended. (Please attach a translated and certified copy of your transcripts for any institution from which you received a diploma or degree). Por ahora, solo adjunte fotocopias de sus creditos. Dates Attended Actual Name of Name of Major Field of (Month, Year) Degree or Diploma Date Received Institution/Location Study From To (Do not translate) Work Experience: List jobs held, begin with current or most recent employment. (Continue on additional sheets of paper, if necessary) IMPORTANTE: Cerciórese de incluir su experiencia laboral que este relacionada con el campo de estudio que desea seguir con el programa CCI. Name and address of employer Position held Date From: Date To: Responsibilities

3 3 If you have traveled or lived in any country other than your own indicate places, dates and purpose. (Continue on additional sheets of paper, if necessary) Indique si son meses o años. Country Dates Purpose Below, provide the names, addresses and telephone numbers of individuals to be notified in case of emergency. Location & address of individual Indicate relation to Languages this Name of individual (List contact in your country and in the individual (relative, person speaks United States) friend, etc.) Essays Essay #1: Please describe why you are a good candidate for the Community College Initiative program. How would this program fit with your past education and training? How would this program fit your future professional and personal goals?

4 4 Essay #2: What would you like to share about your country and its culture with the people you meet? Why would you be a good representative of your country? How will you share your culture with people who may not know it?

5 5 Essay #3: Please describe one situation from your school, work, or personal life when you faced a challenge or a problem. How did you resolve it?

6 6 Essay #4: What do you think will be most difficult about being away from your home for a year? What steps will you take to overcome these difficulties?

7 7 Essay #5: What part of U.S. culture are you eager to experience? Why?

8 8 Essay #6: If you participate in this program, how do you think your life will be different in 5 years? How did you become aware of the CCI scholarship? (Please check all that apply) Friend or family Radio/Television Fulbright Scholar Embassy Web Page University (specify): Social Networks (Facebook/Twitter)(specify): Written media (specify): Other (specify): PLEASE INDICATE IF YOU HAVE APPLIED FOR A U.S. VISA: YES NO DATE (S) GRANTED DATE (S) REJECTED NON-IMMIGRANT VISA (VISA DE TURISMO) IMMIGRANT VISA (VISA DE RESIDENCIA) ESTÁ EN TRÁMITES DE VISA DE RESIDENCIA ACTUALMENTE? ALGÚN OTRO TIPO DE VISA? INDIQUE CUAL: TIENE ALGUNA VISA EN PROCESO? INDIQUE CUAL:

9 Are you a Panamanian citizen? Yes No If no, please indicate of which country you are a citizen. 9 Do you have or are you in the process of obtaining a Green Card or citizenship to the United States? Yes No If yes, please indicate which one and what date you applied. Do you have or have you had a U.S. passport? Yes No COMMUNITY COLLEGE INITIATIVE PROGRAM APPLICATION CERTIFICATION STATEMENT CERTIFICATION: I certify that I completed this application myself, without aid or assistance, that the information given in this application is complete and accurate, and that I have carefully read and understand it. I understand that program administrators reserve the right to verify all the information listed in the application. I understand that giving false or misleading information in the application will eliminate me from the competition or cause my dismissal from the Community College Initiative Program. Also, I acknowledge that I am aware of the following program requirements: I must follow all program rules and regulations and observe all the laws of the United States during my stay there. At the end of the year program, I will return to my home country. I understand that I may not extend my stay in the United States. Signature of applicant Date (month/day/year) La solicitud completa puede ser entregada en cualquiera de estas tres formas: Por transporte o personalmente al Complejo de la Embajada de EE.UU. (Garita de Servicio) Calle Demetrio B. Lakas, Edificio 783, Public Affairs Section (Exchanges), Clayton Por fax al enviar Atención Becas/Programa CCI Por a: Fecha de entrega: Antes del 20 de diciembre 2012 (antes de las 5:00 p.m.) APPLICATION CHECKLIST Incomplete applications will not be considered. Complete applications should include the following: Completed and signed Application English Test - Institutional or Official TOEFL or TELP Score (if taken): Date taken: Photocopy of secondary school diploma (No translation required at this time) Photocopy of secondary school transcripts (No translation required at this time) Current university transcripts, if currently a student Photocopy of university diploma/ transcripts (No translation required at this time) Clear photocopy of your passport bio page. If you do not have a passport, do not obtain one. In absence of a passport, please include a clear readable photocopy of your cedula.

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