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
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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