2015 BENJAMIN FRANKLIN TRANSATLANTIC FELLOWS INITIATIVE:
SUMMER INSTITUTE FOR YOUTH
(June 27 – July 25, 2015)
NOMINATION FORM
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Last (Family) name as on passport:
First names as on passport:
Middle name(s) as on passport:
Date of birth (month/day/year):
City of birth:
Country of birth:
Country of residence:
Country of citizenship:
Gender:
Position: Secondary School student
Nominee’s full address (include apartment number, street, city, state, and
postal number):
L. Home telephone number:
M. E-mail address(es):
N. Medical, physical, dietary or other personal considerations (please note,
no physical examination is required to participate in the program):
O. Name of nominee’s high school:
P. Nominee’s field of study (if applicable):
Q. Other educational, academic and professional experience or training.
Please also note any specials honors or awards received:
R. Work experience, including positions and titles (if applicable)L
S. Active memberships:
T. Specials interests and extracurricular activities:
U. Previous travel in the United States:
V. Evidence of competence in written and oral English:
W. Future study or career plans: