COMMUNITY COLLEGE INITIATIVE PROGRAM STUDENT APPLICATION

Transcripción

1 COMMUNITY COLLEGE INITIATIVE PROGRAM STUDENT APPLICATION DEADLINE: 8 November 2010 before 11a.m. IMPORTANT: Do not leave blank spaces. Please complete your application in English. Personal Information Name of applicant SURNAME FIRST MIDDLE Escriba su apellido en MAYUSCULA. Home Address (Street and number; city, state/province, postal code): Home Phone: Escriba el nombre de la calle, barriada, ciudad o pueblo, provincia. Mobile Phone: Place of birth (city or town and country, as listed in passport, if available): Ciudad, provincia, y país. of birth (month/day/year): Country of citizenship: Gender: Male Female Marital status: Single Married What is the highest educational degree you have completed? Ejemplo High School diploma in Science, Letters, etc. Do you have a passport? yes no Are you currently a student? yes no If yes, name of college/institution: Si es Licenciatura Bachelor s degree in Your proposed field of study (check one): Agriculture Applied Engineering Business Management and Administration Health Professions* Media Tourism and Hospitality Management Information Technology Within your proposed Field of Study, your specific area of interest is: *Limited availability of placement Cerciórese de mencionar si tiene un área específica de interés dentro de su campo de estudio. A program of the United States Department of State, Bureau of Educational and Cultural Affairs: AY Page 1

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 provide a copy of the test results. Test Taken: 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. s Attended Actual Name of Name of Major Field of (Month, Year) Degree or Diploma Received Institution/Location Study From To (Do not translate) Work Experience: List jobs held, begin with 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 From: To: Responsibilities A program of the United States Department of State, Bureau of Educational and Cultural Affairs: AY Page 2

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 s 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 individual Name of individual (List contact in your country and in (relative, friend, etc ) the United States) Essays Essay #1: Please describe why you are a good candidate for the program. What do you hope to learn? How would this program fit with your past education and training and with your future professional and personal goals? A program of the United States Department of State, Bureau of Educational and Cultural Affairs: AY Page 3

4 Essay #2: What would you like to share about your culture? Why would you be a good representative of your country? 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? A program of the United States Department of State, Bureau of Educational and Cultural Affairs: AY Page 4

5 Essay #4: If you participate in this program how do you think your life will be different in 5 years? 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 A program of the United States Department of State, Bureau of Educational and Cultural Affairs: AY Page 5

6 PLEASE INDICATE IF YOU HAVE APPLIED FOR A U.S. VISA: DATE (S) DATE (S) NON-IMMIGRANT VISA (VISA DE TURISMO) YES NO GRANTED REJECTED 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: Signature of applicant COMMUNITY COLLEGE INITIATIVES PROGRAM APPLICATION CHECKLIST 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, Clayton - Tel: Por fax al enviar Atención Becas/Programa CCI Por a: [email protected] Fecha de entrega: 8 de noviembre de 2010 (antes de las 11 a.m.) APPLICATION CHECKLIST Incomplete applications will not be considered. Complete applications should include the following: Application English Test - Institutional or Official TOEFL or TELP Score: (if taken) taken: Current Transcripts, if currently a student Photocopy of secondary school diploma o Translation do not submit at this time. Photocopy of secondary school transcripts o Translation do not submit at this time. Photocopy of university diploma/ transcripts o Translation do not submit 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. A program of the United States Department of State, Bureau of Educational and Cultural Affairs: AY Page 6