Study of the U. S. Institutes for Student Leaders Program fy 2017 Application Form

Study of the U.S. Institutes for Student Leaders Program

FY 2017 Application Form

1. 
   Current Academic Institution and City Name
   

Institution and City Name:      

2. 
   Candidate’s Full Name, exactly as it appears on passport
   

Prefix:      

Last Name:      

First Name:      

3. 
   Gender
   

Male:      

Female:      

4. 
   Date of Birth (please spell out Month, Day, Year)
   

     

5. 
   City of Birth:      
   
6. 
   Country of Birth:      
   
7. 
   Citizenship:
   

Primary:      

Secondary, if applicable:      

8. 
   Country of Residence:      
   

9. 
   Medical, Physical, Dietary or other Personal Considerations
   

     

10. 
    Contact information
    

Address:      

City:      

Home State or Province:      

Home Country :      

Residence Phone no:      

Mobile No:      

Email:      

11. 
    Emergency Contact
    

Name and Relationship:      

Phone number:      

E.mail address:      

12. 
    About Family
    

Parent or Guardian	Name	Occupation
Father	     	     
Mother	     	     

Address (if different from yours):      

Telephone:      

Email:      

Brothers/Sisters

Name	Gender	Age	Occupation
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

13. 
    Education
    

Current

Education, Academic and Professional Training, including degree earned and fields of specialization

Degree	Year in School	Specialization/ Institution	City	Expected Graduation Date	Grade/GPA
     	     	     	     	     	     

Previous

Degree Earned	Year Earned	Specialization/ Institution	City	Grade/GPA
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     

14. 
    Scholarship
    

Are you currently on or have you ever earned any kind of scholarship (if yes, please provide details) :

     

15. 
    Work and Volunteer Experience:
    

     

16. 
    Memberships in Associations, Clubs, etc:
    

     

17. 
    Previous experience in the United States: Please list any and all trips the candidate has made to the United States and include approximate dates and the reason for travel.
    

Purpose	Travel Dates	State/City	Description
     	     	     	     
     	     	     	     

18. 
    Previous experience in any other county abroad: Please list any and all trips the candidate has made to any contry outside Pakistan and include approximate dates and the reason for travel.
    

Purpose	Travel Dates	State/City	Description
     	     	     	     
     	     	     	     

19. 
    Family Residing in the United States: Please list any immediate family members (parents and siblings if unmarried/spouse and children if married) who are currently residing in the United States, including city and state.
    

Name	Relationship	State/City	Occupation
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

20. 
    Personal Statement (Please structure your essay in paragraphs and limit your response to 250 words, single-spaced. Essays that exceed the word limit are penalized in the scoring.)
    

Tell us about yourself and your goals including the following:

• 
  What about you background and/or interests make you 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?
  

     

21. 
    Short answer questions
    

The short answer questions are an essential part of the selection process. Please structure your response using paragraphs and limit your response to 150-250 words.

1. 
   If you had the opportunity to implement one policy at the national level in Paksitan, what would that policy be, and why?
   

     

2.   What is one initiative that you would personally like to start at your local neighborhood or community level? What support will you need, and who can you enlist to help you? How would you measure the success of your initiative?