Application
(Please print clearly in ink or type responses)
1 Legal Name:
Last (family) First (given) Middle (if none, indicate none)
2 Mailing Address:
Street Apartment name and number (if applicable)
City Province or state Postal or zip code Country
3 Email:
5 Country of Citizenship:
7 Date of Birth:
4 Telephone:
6 Academic Major:
Month Day Year
8 Personal Statement (required)
Please respond to the following question in the form of a 500-1000 word written essay or a 2-5 minute video. Essays may be written
in the space provided, or you may attach your response to this application. When submitting a video, please include a direct link to
your uploaded video via YouTube, Vimeo or similar platform. Please do not send us the video file.
Tell us about your leadership skills in your school or community, and how you plan to continue applying your leadership skills at the
U.S. institution you are applying to.
□ I agree that my name, country of origin, academic major, photo and essay may be shared publicly in promotion of
#YouAreWelcomeHere if I am selected for an award.
Applicant’s Signature Date
X
