APPLICATION

MOROCCO
2011 STUDY OF THE UNITED STATES INSTITUTE
FOR STUDENTS ON WOMEN’S LEADERSHIP

Instructions

1. Complete the application below directly in this document. Incomplete

applications will not be considered.

2. Submit your application by e-mail to rabatyouth@state.gov or by fax to

0537-66-8299 by Tuesday, December 21, 2010. E-mail submission is
preferred. No late applications will be accepted.

3. For more information, please contact the Public Affairs Section at

rabatyouth@state.gov or call 0537-66-8045.

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A. Title of Institute: 2011 Study of the United States Institute for
Student Leaders on Women’s Leadership

B. Full Name

 First Name:

 Middle Name:

 Last (Famiy) Name:

If you have a passport, please note that your name must be written exactly as it
appears and please provide copies of the first three pages of your passport.

C. Gender: ***This institute is open to women applicants only.***

D. Date of Birth:

E. City of Birth:

F. Country of Birth:

G. Country of Citizenship:

H. Country of Residence:

I. Medical, Physical, Dietary or other Personal Considerations:

Please state if you have any existing medical conditions or are currently taking
any prescription medication. This will not affect the selection, but will enable the
host institution to make any necessary accommodations.

J. Contact Details

 Home Address:

 Telephone:

 E-mail:

 Parent/Legal Guardian Name:

 Parent/Legal Guardian Telephone +

 Parent/Legal Guardian E-mail:

K. School/University

 Academic major:
 Name of School/University: ()

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  City:

L. Work and Volunteer Experience:

M. Year in School:

N. Memberships in Associations, Clubs, etc. :

O. Previous Experience in the United States:

None

P. Family Residing in the United States:

None

Q. Evidence of English Fluency:

R. Statement by Post Justifying Participation of Nominee:

***Do not answer. This will be completed by the Embassy if you are
selected.***

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S. Personal Statement: