1 Please fill out this form in English as completely as possible, using ...

2008 Self-Nom<strong>in</strong>ation Form<strong>Ple<strong>as</strong>e</strong> <strong>fill</strong> <strong>out</strong> <strong>this</strong> <strong>form</strong> <strong>in</strong> <strong>English</strong> <strong>as</strong> <strong>completely</strong> <strong>as</strong> <strong>possible</strong>, us<strong>in</strong>g <strong>as</strong> much space <strong>as</strong> needed,and email it to your local EducationUSA adviser.NameAddressDate of birth (month, date, year) (ple<strong>as</strong>e, attach the l<strong>as</strong>t page ofyour p<strong>as</strong>sport)Home telephone numberOffice telephone numberCell phone numberE-mail addressEducation received & educational <strong>in</strong>stitution (list all)Have you applied for or participated <strong>in</strong> any US Governmentsponsoredacademic exchanges? If yes, which program andwhen? What stage did you reach (f<strong>in</strong>alist, alternate, semif<strong>in</strong>alist)?Describe your academic achievements and plans for study <strong>in</strong> theUS. Include honors, awards and/or publications.Describe your non-academic achievements (<strong>in</strong> sports, music,community service etc.).Give evidence of your leadership qualities.Are you employed?If so, <strong>in</strong> what capacity?Do you live with your parents? What are your parents’occupations?Describe any special f<strong>in</strong>ancial circumstances.How do you plan to f<strong>in</strong>ance your US education?Are you a member of an ethnic or religious m<strong>in</strong>ority, disabled, ordisadvantaged <strong>in</strong> another manner? <strong>Ple<strong>as</strong>e</strong> expla<strong>in</strong>.What stage of the application process are you currently <strong>in</strong>?<strong>Ple<strong>as</strong>e</strong>, choose from the list below:1. plann<strong>in</strong>g to take standardized tests2. accepted and <strong>in</strong> need of <strong>as</strong>sistance to cover SEVIS andvisa (ple<strong>as</strong>e, attach your I-20)3. If you received a scholarship, ple<strong>as</strong>e, provide aconfirmation letter4. travel <strong>as</strong>sistance5. School selection1