ATTACHMENT_J.12_APPLICATION_TEMPLATE.pdf

Community Connections

Community Connections

Program Application

Instructions Please complete all of the questions in the application. Incomplete applications will not be accepted. The application and your stated interests will be key factors in the development of your program. Please be as specific and thorough as possible. Please type or handwrite legibly in your native language when filling out your application.

Eligibility Checklist

The Community Connections Program does not discriminate on the basis of race, color, sex, religion, national, and ethnic origin, or disability. Persons with disabilities are strongly encouraged to apply. Competition is merit-based and open to anyone who meets the following requirements.

Verify your eligibility by checking each box to indicate that YOU ARE:

A citizen of Belarus.

Residing in Belarus at the time of application and during the selection process.

Able to demonstrate professional aptitude and leadership potential in the chosen field.

Eligible to receive and maintain a U.S. J-1 visa.

Committed to returning to your home country immediately after completion of the program.

Willing to live with a host family in the United States Not to be accompanied by spouse and/or children

Verify your eligibility by checking each box to indicate that YOU ARE NOT:

A U.S. citizen or permanent resident of the United States, or a citizen or permanent resident of a country other than Belarus without Belarusian residence permit.

The spouse of a U.S. citizen or permanent resident of the United States.

Currently residing or working outside of Belarus.

A previous participant in a program sponsored or funded by the U.S. government (e.g. USAID or other U.S.

government agency for a period of more than one week within ten previous years An individual who has applied for an immigrant visa to any country or who has requested political asylum in any country. This includes individuals who hold or have applied for a U.S. "green card".

An employee of the USAID or other U.S. government agency, or the spouse, child, sibling, parent (and in-law), grandparent (and in-law), or grandchild of an employee, or a person in a committed relationship with an employee.

An employee of a Public International Organization

Attachments Checklist & Required Order Please attach the following items to your application. Your application must be submitted in the order given below.

Incomplete or late applications will not be considered.

Completed application form: with one passport photo securely attached in the top left corner of page two. Please submit four copies of this form.

Two recommendations from employers or professional colleagues. Please submit four copies of each recommendation.

One photocopy of the picture page of your passport Resume in native language outlining educational and professional history. Please submit four copies of the resume.

Only selected candidates of the Community Connections program will be notified of their status.

Community Connections

Program Application

I. Personal Information

Last Name (Surname): _____________________________________ First Name: __________________________________

Date of Birth : ________/_______/________ Place of Birth ____________________________________________________ Month Day Year City and Country

Country of Residence: _________________________________ Citizenship: _______________________________________

Gender: female male Marital Status: single married separated divorced widowed

Citizenship of Spouse: __________________________________________________________________________________

Home Address (Street): ____________________________________ Building: _______ House: _______ Apartment: _______

City/Region: ________________________________________ Country: ____________________ Index: _________________

Home Phone (Country Code/City Code): (________)/(________)- ________________________________________________

Mobile Phone (Country Code/City Code): (________)/(________)-________________________________________________

Personal E-mail Address:_________________________________________________________________________________

Current Occupational Title: _____________________________________________________________________________

Place of Employment: _________________________________________________________________________________

Please describe your company’s activities (ex. retail shop selling cosmetics; wholesale of building materials; etc.):

City/Region: ________________________________________ Country: ____________________ Index: ________________

Work Phone (Country Code/City Code): (________)/(________)-________________________________________________

Do you have a disability? Yes No If yes, please describe _________________________________________________ Note: This question is included only for statistical purposes; your response will not affect your eligibility in any way.

Emergency Contacts Please list two people in Belarus to be contacted in case of emergency while you are participating in the program.

A.) Name: ___________________________________________ Relationship to You: __________________________________

Address (Street): _________________________________ Building: _________ House: _________ Apartment: __________

City/Region: _____________________________________ Country: ____________________ Index: ___________________

Telephone: (_____)______________________ Fax: (_____)___________________ Email: __________________________

B.) Name: ___________________________________________ Relationship to You: __________________________________

Address (Street): _________________________________ Building: _________ House: _________ Apartment: __________

Attach Photo Here

City/Region: _____________________________________ Country: ____________________ Index: ___________________

Telephone: (_____)______________________ Fax: (_____)___________________ Email: __________________________

Passport

Expiration date: _______/_____/______ Passport Number: _______________________________ month day year

II. Professional Experience List your most recent professional experience first and include all of the information requested. You will include a copy of your resume with your application, so there is no need to include more than the three most recent positions you have held.

Name & Type of Organization or Company

(Number of employees)

Job Title & Dates of Employment

(Number of people supervised)

Responsibilities

(Number of hours worked per week)

Professional Memberships List professional associations or other organizations in which you currently are involved or with which you have been involved in the past. Include approximate dates of affiliation.

III. Foreign Language Ability List all languages you know and your native language. Rate your reading, writing, and speaking skills in each language: mark an X in the appropriate box

ENGLISH: _____________________

Reading Writing Speaking Excellent Good Fair Poor

OTHER:

Good

OTHER: _____________________

Good

IV. Education:

List all educational institutions you have attended, beginning with the one you attended most recently. For the “Degree or Diploma” column, write the name of your degree/diploma directly into Latin letters. Do not use American equivalents such as bachelor’s degree or master’s degree, unless it was the actual name of the degree awarded by your institution.

Institution & Location Major Field of Study Dates of Study

Degree or Diploma

Academic Awards Please list, provide a date, and describe any awards or honors you have received. Some examples of academic honors are: graduation with distinction, graduation from school with a gold or silver medal, awards received etc.

V. International Experience List your travel abroad over the past five years. Please indicate the places you visited, the dates of your stay, and the reason for your trip(s) (starting with the most recent trip first).

Have you ever been to the United States on a J visa (exchange visitor)? Yes No

If yes, please indicate in which program(s) you participated, the duration of the program(s), the dates of the program(s), and the organization or U.S. government agency that sponsored your program.

VI. Previous Applications If you have previously applied to the Community Connections Program, indicate the professional field (business, other) to which you applied, your status (applicant, semifinalist, alternate, finalist), and the year in which you applied.

VII. Professional Information

1. Please describe your organization and its goals?

2. Describe your position and responsibilities (be specific)?

3. What challenges do you face in your position?

4. What are your professional goals for the next five years?

5. What practical experience would you like to gain from your program in the US?

6. What topics would you like discussed during weekly professional development seminars?

VII. Supplemental Information

This information will help your host organization and host family to make you more comfortable and to create a better plan for your stay in the United States.

What do you like to do in your free time?. Describe your hobbies and interests?

How would you describe yourself to a U.S. host family?

Besides visiting historical and geographical sites, what cultural or free-time activities or events would you like to participate in or see while in the United States?

Yes No Do you smoke?

Yes No Do you have any allergies?

Yes No Do you have any medical conditions or physical limitations?

Yes No Do you take any medication?

Yes No Do you have any special dietary needs?

Recruitment Question

Please indicate how you learned about the program (check all responses that apply). This information will not be used in the evaluation of your application. It will help the program administrators plan the advertising and recruiting campaign for the next competition.

USAID Mission Educational Information Center Community Connections Program Office U.S. Embassy, Consulate, or Public Affairs Section Resources at Your Workplace Colleague Community Connections Alumnus or Alumna Friend Lecture by Community Connections Representative. How did you learn about the lecture?

Newspaper/Journal: (name; date) Television: (station; date) Radio: (station) Internet: (site address) Other (please describe)

The Community Connections Program reserves the right to verify all of the information indicated in any application.

In the event that there is a discrepancy, or information is found to be false, the application will be declared invalid, and the applicant ineligible. Please sign below.

I certify that the information given in this application is complete and accurate to the best of my knowledge. I understand that the final approval of my application and my status as a program grantee is dependent on my placement at an appropriate U.S. internship and on my ability to receive and maintain a U.S. J-1 (exchange visitor) visa. As required by the terms of the grant and the J-1 visa, I agree to return to my home country for two years immediately upon the conclusion of the fellowship.

Signature Date

RECOMMENDATION FORM

Information about Applicant: To be completed by the applicant. Please print clearly or type.

Last Name (Surname) First Name Patronymic

Professional Field Home City, Region

Instructions: The remainder of this form should be completed by an employer, supervisor, or professional colleague, who is familiar with the applicant. Your candid, honest response will assist us in selecting successful candidates and placing them in internships that best meet their personal and professional goals.

Please note the following important guidelines:

• Recommendations written in a language other than English must be accompanied by an English translation.

• Recommendations must be signed and must include the name, address, and telephone number of the person providing the recommendation.

• Recommendations must also have the stamp or seal of the organization at which the person providing the recommendation works.

Completed recommendation forms should be returned to the applicant for submission with his or her other application materials. If you do not want the applicant to read your recommendation, please make two copies, enclose each one in a sealed and signed envelope, and give the three envelopes to the applicant to submit by the deadline. Indicate that you are enclosing your recommendation in a sealed and signed envelope by checking the appropriate box on the next page of this form.

In what capacity, and for how long, have you known the applicant?

Please rate the applicant in the following areas: (write X in the appropriate box)

Excellent Good Fair Poor Unable to Judge

Leadership Potential

Professional Aptitude

Flexibility

Motivation

In your opinion, what is this applicant’s best quality?

Please describe why you believe the applicant is prepared for a professional internship in the U.S. in the chosen field. Cite examples from the applicant’s professional background to support your conclusions.

In what ways do you see this applicant making a difference, upon return, in his/her home country and in his/her professional field?

Please share a concrete example of a specific accomplishment the applicant has made in his/her field.

Name and Title (please print):

Place of Employment:

Address (Street): _________________Building: _____ House: _____ Apartment:

City/Region: Country: Index:

Work Telephone: E-mail:

Signature: Date: