CIEE WAT Scholarship Nomination 2016 Form Final .pdf

Nom original: CIEE WAT Scholarship Nomination 2016 Form_Final.pdf

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PERSONAL INFORMATION (Print your name exactly as it appears on your passport.)
Last Name:
Middle Name:
First Name:
Email Address:

  Female      Male

Date of Birth (DD/MM/YYYY):
Country of Birth: City of Birth:
Country of Study:
Passport Number:
Please check these boxes to confirm the required documents are submitted with your scholarship nomination form:

Copy of passport ID page

Copy of your resume

Departure and Return dates are based on your country’s permitted DS start and end dates, your academic calendar, and your desired travel period.

Permitted DS-2019 Start Date (DD/MM/YYYY):

Permitted DS-2019 End Date (DD/MM/YYYY):

Arrival Date in U.S. (DD/MM/YYYY):
Cannot arrive more than five days prior to DS-2019 start date.

Desired Job Start Date (DD/MM/YYYY):
When do you want to start work in the U.S.?

Desired Job End Date (DD/MM/YYYY):
When do you want to end work in the U.S.? Can be no more than four months after the job start date.

Date of Departure From U.S. (DD/MM/YYYY):

Cannot leave the U.S. more than 30 days after DS-2019 end date and no more than five months after arrival date.

Name of University/College:
Major Field of Study:
Years Attended:

1-888-COUNCIL (268-6245)

Updated: 8/16/16

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SUPPORTING STATEMENT (Please submit a 300-500 word essay or 1-2 minute video link on the following topic.)
The goal of CIEE Work & Travel USA is to increase mutual understanding between Americans and citizens of other countries. Are you a global
citizen? Tell us what you hope to gain from living and working in the United States through this exchange program.

APPLICANT DECLARATION (Applicant signature is required.)
I will be able to successfully interact in an English-speaking environment. I have sufficient English proficiency to navigate daily life, read and
comprehend materials, and know how to obtain assistance, if necessary, in an English-speaking environment.
If I am selected to receive a CIEE scholarship, my name, photo, academic major, and location of my Work & Travel USA program may be used
for promotional materials.
Applicant’s Name (Please Print):
Applicant’s Signature: Date (DD/MM/YYYY):

1-888-COUNCIL (268-6245)

Updated: 8/16/16

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