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.