Please send your completed application no later than March 22, 2015 to Public Affairs Section, U.S. Embassy Minsk via email: belarusprogram@state.gov
A. Last (family) name as in passport:
B. First name as in passport:
C. Middle name(s) if on passport:
D. Date of birth (month/day/year):
E. City of birth:
F. Country of birth:
G. Country of residence:
H. Country of citizenship:
I. Gender:
J. Position:
K. Home full address:
L. Home telephone number:
M. E-mail address:
N. Medical, physical, dietary, or other personal considerations (at this time, no physical examination is required to participate in the program although the U.S. host institution may have specific requirements):
O. Name of the high school or college/university where you study:
P. Field of study (if applicable):
Q. Any other relevant educational, academic and professional experience or training:
R. Active memberships, special interests, or extracurricular activities:
S. Previous travel and study experience in the United States. Please include dates and indicate whether such travel was supported by U.S. government funds:
T. Evidence of competence in written and oral English (e.g., personal interview, test score, teacher recommendations etc.):
U. Future study or career plans:
V. Written Essay (not to exceed 500 words): “Why Transatlantic Cooperation is Important to My Life and to the Future of Belarus”.
W. Attach two recommendations from teachers regarding your academic achievements and leadership potential.