FORTUNE/U.S. State Department

Global Women’s Mentoring Partnership

Application Checklist

Name
Age
Gender
Governorate
Previous travel to the U.S.? If yes, please specify duration and type of visit
Egyptian Citizen / ÿ  Yes
ÿ  No
Number of Years of Work Experience
Current Employer
Have you ever worked for a Fortune 500 Company? / ÿ  Yes
ÿ  No
Level of Education (bachelors, masters, PhD, other)

In order for your application to be complete, please make sure you have:

ÿ  Completed Application Checklist Form (this page)

ÿ  Completed Application form (pages 2- 6 of this document)

ÿ  Copy of National ID and/or passport

ÿ  Most recent curriculum vitae

* Completed applications and required attachments must be received via e-mail by January 3, 2012 at 4:30 p.m. Any applications received after this time will not be considered. Please e-mail all applications and supporting documents to:

For more information on the program, please visit: http://exchanges.state.gov/citizens/professionals/fortunepartnership.html

FORTUNE/U.S. State Department

International Mentoring Partnership

Application Form 2012

A. Name: ______

(First name) (Middle name) (Last name)

B. City and Country of Birth: ______

C. Date of Birth written in full: ______

(Month) (Day) (Year)

D. Passport no: ______

Date of issue: ______

Date of expiration: ______

E. Marital Status:______

F. Citizenship: ______

G. Special considerations, such as allergies, medical and physical challenges, dietary preferences:

H. Does nominee smoke? Yes ( ) No ( )

I. Business address, telephone and fax numbers:

J. E-mail address:

K. Home address and telephone:

L. Preferred Mailing Address: Business ( ) Home ( )

M. Languages:

1) Native Language:

2) English Proficiency: (5 point FSI scale)

Speaking:

Comprehension:

Written:

N. Present Position: (exact title, starting date, and brief description of role in company)

O. Full Name of Company or Institution:

P. Brief Description of Company/Institution: (Please include type of industry, number of employees, annual budget, etc.)

Q. Publications (if any):

R. Professional memberships in local, national or international professional organizations or associations or clubs:

S. Previous Travel to the United States: (Please note if grantee has ever traveled on a U.S. Government program)

Dates:

Places Visited:

Sponsorship/Purpose of Visit:

T.  Other Travel Abroad

Dates:

City and Country:

Principal Purpose of Visit:

Dates:

City and Country:

Principal Purpose of Visit:

Dates:

City and Country:

Principal Purpose of Visit:

U. Educational Background: (List highest degree first. Include significant training programs.)

Dates:

Degree/Certificate:

Institutions:

Field of Specialization:

V. Other Interests: (Sports, Hobbies, Volunteer Activities)

PERSONAL STATEMENT

Please answer all of the following questions in your personal statement: This can be more than one page, but it is important that all four questions are answered in the following order.
1- Why do you think you will be a good fit for this exchange program?
2- What do you hope to gain from being mentored by a top U.S. female business executive?
3- What are your personal interests outside business?
3- How do you expect the program to impact your work when you return to Egypt?

RECOMMENDATION CONTACT

Identify one individual who can provide you a letter of recommendation. Please have this recommendation letter ready with you if you are called back for an interview.

Name
Title
Mailing Address
Telephone Number
Email Address

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