APPLICATION FORM

“Mentoring and Leadership program for Eurasian Women”

10th – 27th September 2012, Poland

Please send the completedApplication Form toLudmila Bilevschi, U.S Embassy Alumni and Speaker Program Specialist,byJuly 10, 2012, 14:00 at (tel. 022851709).

  1. Name and Surname:
  2. Date and city/country of birth:
  3. Nationality:
  4. Marital status:
  5. Passport number:

Date of passport issue: Date of expiration:

  1. E-mail address:
  2. Facebook page address:
  3. Mobile phone:
  4. Address (street, apartment number, postal code, city, country):
  1. Contact address (please fill in case it differs than address in point. 9)
  1. Education (Please give information about the graduated schools, titles, specialization, names of diploma etc.)
  1. Please specify your actual place of employment, position held and give brief scope of duties.
  1. English language (please rank your knowledge of English in a scale 1-5) as well as give the names of graduated exams/diplomas.
  1. Please specify organizations/institutions/associations or political parties in which you are actively involved (if any):

- date from when you joined the organization

- organization’s mission and goal

- what is your position there and tasks

- with whom you cooperate within this organization.

  1. Please specify your pro publico bono activity (if any):

- when you were involved in pro public bono activity

- for which social groups

- what was your role and tasks

  1. Please specify titles of your publications as well as date of publishing (if any)
  1. Please enclose your actual CV and photo (head shot).
  1. What are your plans for the future career development ?
  1. Have you already traveled to Poland before ?(if so, please give the date and the purpose).
  1. Please give information about your health, diet or other importance in order to plan your stay properly.
  1. What are your expectations about “Mentoring and Leadership Program” which is to take place in Poland? What kind of information you would like to get? What is your goal and purpose to participate in this program? What issues or topics are the most interesting for you?
  1. What are your suggestions concerning staying in Poland: please specify your professional interests, which could potentially be included in the program, contacts or people you would like to meet, topics for discussion which you would like to discuss with them. Please also specify your cultural and touristic preferences.
  1. Is there any other information you would like to give us, which are crucial to be qualified in this program?

Name and Surname (signature)City, date

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