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GREEN CARD LOTTERY QUESTIONNAIRE 
 
PETITIONER: FULL NAME 
/ 
first name middle name family name 
DATE OF BIRTH:__
/
month day year 
PLACE OF BIRTH:
/
city region country 
ADDRESS______________________________________________________ 
house number street room number 
_______________________________________________________________ 
city state zip code 
TELEPHONE___________________________________________________
/ 
(
(city code) 
HUSBAND’S (WIFE’S) FULL NAME: 
_______________________________________________________________ 
first name middle name family name 
DATE OF BIRTH: _______________________________________________ 
month day year 
PLACE OF BIRTH: ______________________________________________ 
city region country 
CHILDREN (below 21 year old, not married) 
1. FULL NAME: _________________________________________________ 
first name middle name family name 
DATE OF BIRTH: _______________________________________________ 
month day year 
PLACE OF BIRTH: ______________________________________________ 
city region country 
2.FULL NAME: _________________________________________________ 
first name middle name family name
DATE OF BIRTH: _______________________________________________ 
month day year 
PLACE OF BIRTH: ______________________________________________ 
city region country 
46 

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APPLICATION FOR
THE 2005 RUSSIAN SCHOLARS EXCHANGE PROGRAM
Attach here a photograph
taken within the last year.
(Make sure your name is
written on the back)
1. NAME OF APPLICANT (Enter full, legal name, underline family name)
2. PLACE AND DATE OF BIRTH (City or town, and country)
3. CITIZENSHIP
6. Permanent Address (in English) __________________________________________________________
___________________________________________
_______________
___________________________________________
_______________
7. Home Telephone: _________________________
Institution and Location
(List chronologically)
Institution and Location
(List chronologically)
University or Institute
Secondary School
Major Field
of Study
Classes Taught (Specify Department.)
Dates
(Month and year)
From to
Actual Name of 
Degree or Diploma 
(Do not translate)
Date Received or 
Expected and Grade 
Point Average
9. MARITAL STATUS (Single, married, widowed,
or divorced) AND CITIZENSHIP OF SPOUSE
(if applicable)
11. INDICATE THE PROGRAM FOR WHICH YOU ARE APPLYING:
12. PROVIDE A BRIEF SUMMARY OF YOUR RESEARCH PROPOSAL. Attach your seven-page research 
proposal to the application.
13. EDUCATION: LIST EDUCATIONAL INSTITUTIONS ATTENDED AND ANY IN WHICH YOU ARE
PRESENTLY ENROLLED. (Read instructions before completing this section. Do not translate the names of
degrees and diplomas; use the words attestat, diploma, or candidate of science, etc.)
14. INDICATE ANY ACADEMIC HONORS YOU HAVE RECEIVED. (Include dates.)
15. LIST ALL TEACHING POSITIONS HELD. (Read instructions before completing this section.)
Three-month:
Nine-month:
10. LIST AGES OF CHILDREN (if any)
Work Telephone: ___________________________
Fax Number: _______________________________
INDICATE CURRENT STATUS: Graduate Student:
or Young Faculty:
5. CURRENT PLACE OF STUDY OR EMPLOYMENT: _________________
________________________________________________________________
4. GENDER
Female
Male
Day Month Year
47 

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