2022 SUSI APPLICATION FORM
YOUR NAME ________________________________________________________________________________
(as it appears on your passport) Family First Middle
CONTACT INFORMATION
Current address: Home address:
___________________________________________________
_________________________________________
_________________________________________
E-mail address: _________________________
Home telephone: ___________________ Mobile telephone: _____________________
PERSONAL INFORMATION
Gender: Male Female Date of Birth:
Day / Month / Year
Country of Citizenship: Country of Birth:
Country of Residence: City of Birth:
ACADEMIC INFORMATION
School Name: Year of study:
When will you graduate? ______________________________
What diploma will you receive? _________________________
How many years of study does your field require? _________________________
HONORS/AWARDS
Please list any special honors or awards you have received:
______________________________________________________________________________________________
YOUR NAME
(as it appears on your passport) Family First Middle
REFERENCES
Please provide the name of a teacher or professor who has agreed to serve as a reference for your application.
Reference Name: Title:
Email address: __________________________________ Mobile Phone:
ENGLISH PROFICIENCY
Speaking: Excellent Reading: Excellent Writing: Excellent
Good Good Good
Fair Fair Fair
WORK EXPERIENCE (if applicable)
Please start with your most recent position. You may include volunteer activities and internships.
Name of Employer and
Location
Your Job Title and Responsibilities
Dates of Employment
MM/YY – MM/YY
From:
To:
From:
To:
TRAVEL EXPERIENCE
Please describe any previous travel or study in the United States or any other country. If you have not traveled out of your
country, indicate “none.”
Travel Dates
MM/YY – MM/YY
Travel Purpose
(e.g. vacation, school, etc.)
US Government
Program? Y/N
From:
To:
From:
To:
FAMILY IN THE UNITED STATES
Please provide the contact information of your family member in the U.S.
Name: __________________________________Relationship to you: _____________________
Email address: __________________________________ Mobile Phone:
Home address: __________________________________________________________________________________
YOUR NAME
(as it appears on your passport) Family First Middle
EMERGENCY CONTACT
Please provide the contact information of a contact that can be called in case of an emergency
Name: __________________________________Relationship to you: _____________________
Email address: __________________________________ Mobile Phone:
Home address: __________________________________________________________________________________
EXTRACURRICULAR ACTIVITIES (if applicable)
Please describe any activities, clubs, or organizations in which you participate. You may include volunteer and sports
activities.
Name of Activity
Describe the activity
and your role
Dates of Involvement
MM/YY – MM/YY
From:
To:
From:
To:
From:
To:
From:
To:
MEMBERSHIPS (if applicable)
Please list your membership in any other organizations:
SPECIAL INTERESTS (if applicable)
Please describe any hobbies or special interests:
PERSONAL STATEMENT
In a separate word document with your name typed on the top, please respond to the following question: Tell us
about yourself and your goals including the following: What about your background and/or interests makes 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? How will it affect you personally?
Please structure your essay in paragraphs and limit your response to 250 words, or approximately half a page, single
spaced.
YOUR NAME
(as it appears on your passport) Family First Middle
SHORT ESSAY #1 (Approximately150-200 words)
What are your career goals? How will leadership training help to prepare you to meet these goals?
SHORT ESSAY #2 (Approximately 150-200 words)
Identify one political, social, or economic challenge facing your country today. What steps could be taken to
solve the problem or improve the situation? What role can students play in this process?
DISCLAIMER (all applicants)
The information in this application is accurate and complete. The written work in the short essays is my own,
and I have not been assisted by any other person, nor have I copied text from a website or other source. (NOTE:
Your application may be rejected due to plagiarism [French “plagiat”].) I understand that I may be required to
verify information in this application by providing documentation including (but not limited to) transcripts, test
scores, and writing samples. I also understand that intentionally falsifying information in this application could
be grounds for disbarment from U.S. Government funded exchange programs.
Signature (Print your full name): ____________________________________________________
SOCIAL MEDIA (Facebook – Twitter – Website)
I give my permission to have my postings used by the U.S. Department of State and/or program implementing
partners. This may include photographs, video recordings, tweet, blogs, etc. posted in connection to the
program activities.
Signature (Print your full name): ____________________________________________________
