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APPLICATION FOR THE

2013
100,000 STRONG SCHOLARSHIPS

APPLICATION DEADLINE:
November 15, 2012


Please submit your application to:

Carmen Foncea
Cultural Affairs Specialist, U.S. Embassy Guatemala
Avenida La Reforma 7-01 zona 10
FonceaC@state.gov







Please provide all answers in English. Please use a paper/binder clip to hold application materials together.Do not staple.


NAME
Please print your name clearly exactly as it appears on your passport, cedula, or DPI.


Last First Middle

Please indicate any other spelling(s) or name(s) you use:
_____________________________________________

HOME COUNTRY CONTACT INFORMATION

Permanent mailing address in Guatemala:Street: _________________________________________

Mailing: (if different, e.g. PO Box) __________________

City: __________________________________________

Country: _______________________________________

Home telephone: __________________________ Mobile telephone:

E-mail address: ___________________________________________

If yourstreet address (e.g. 200 meters from…) is different from your mailing address (e.g. PO Box), please provide both.

PERSONAL DATA

Sex:  Male  Female Date of Birth: Place:
Month/Day/Year City Country

Country of permanent legal residence: __________________________ Country of citizenship:



EMERGENCY CONTACT INFORMATION
Please provide the names and contact informationof individuals who should be notified in case of an emergency.

Contact in Guatemala:
Name Relationship to you Street Address


City State and/or Country Telephone Number E-mail address




NAME (Please print your name here):


If you are currently enrolled as a university student, name your university:

How many fullacademic years of university study you have completed (please check one below):

 1 year  2 years  3 years  Other ______________________________________


REFERENCES
Please identify the three (3) individuals who could provide a reference on your behalf if contacted. At least one should be from your current institution. Make sure these are people who know your academic andpersonal qualities well.

1. Name: Title:

Mailing address:

Telephone number: E-mail address:

2. Name: Title:

Mailing address:

Telephone number: E-mail address:


3. Name: Title:

Mailing address:

Telephone number: E-mail address:NAME (Please print your name here):


PREVIOUS ACADEMIC SCHOLARSHIPS
Please indicate any scholarships, academic awards or honors that you have received and the year received:






EDUCATIONAL BACKGROUND
Please provide complete information about all the educational institutions that you have attended and, if applicable, information about theinstitution(s) at which you are presently enrolled. You must attach official transcripts for undergraduate study (with English Translations) and official results of the general secondary school leaving exam.

Institution Name
(No abbreviations)
Institution Location
(City, Country)
Dates Attended
MM/YY – MM/YY
Major Field
of Study
Degree Received and Date Received*
Grade Point Average**Primary School:






From:
To:



Secondary School:






From:
To:



Post-Secondary Education:
(University)








From:
To:



* Please identify the name of your degree by the word used at the institution that awarded you the degree. Do not provide the name of the U.S. educational system’s equivalent. If you have not yet received the degree, please...