Competitive College Club Application Form 2013 2014

All sections should be completed electronically and in English

Personal Data Full Name: Family, First Patronymic Permanent Home Address: Street, House, Apartment, Home Phone (with city code): Mobile Phone: Date of Birth: (dd/mm/year) ___Belarus Citizenship: ___Russia (mark all that apply) ___Ukraine Do you have relatives in the US? Have you ever applied for a US visa? Male: ___ Female:___ Date:

City, Oblast, Country, Index Code Email address:

Place of Birth: (city, country) ___Dual US/___ ___US Permanent Resident (list country) ___Yes Ethnicity (optional): ___No Disability (optional): ___Yes If yes, list US visa type, date(s) ___No and purpose of your travel: Plans for Study in the US Career plans: Other:

Field of Study:

Progress in application process:

(mark all that apply)

___Just starting ___Choosing/have chosen US universities to which Id like to apply ___Taking/have taken entrance exams (SAT, ACT, TOEFL, etc.) ___Yes ___No If so, list any scholarships you plan to apply for:
___Yes ___None Some funds, but only for: ___tuition/fees ___housing/food

Will you apply for financial aid offered by US universities? Will you applying for other sources of financial aid? ___Yes ___No

Do you have any personal/family funds to cover the cost of your education in the US?

US Universities: List colleges/universities to which you will apply (if you know already). 1. 2. 3.
Current educational institution (name, city department): Test type: ___Paper-based (PBT) ___Internet-based (IBT) Date: Verbal Subject: Subject: Math: Reading:

4. 5. 6. Current Studies
Entry date: Graduation Date: Type of institution: ___Public ___Private

Test Information/Results TOEFL SAT (Reasoning) SAT Subject SAT Subject English: ACT
Date Taken: Math: Date: Date: Science: Score: Score: Composite: English/Writing: Score: Writing

Academic Honors / Awards / Scholarships / Exchange Programs List any academic honors, scholarships received, or US-government student exchange programs in which you have participated since 9th grade: 1. 2. 3. 4. Family Background Parent/Guardian (1)
(Family Name, First Name Patronymic): Home address (if different from yours): Cell phone: Email: Home phone: Occupation: University attended: Name of Employer: Highest education degree: Living?

Parent/Guardian (2)

(Family Name, First Name Patronymic): Home address (if different from parent 1): Cell phone: Email: Home phone: Occupation: University attended: Parents marital status: With whom do you live: Number of siblings: ___ Never married ___ Both parents Names of brothers/sisters: Name of Employer: Highest education degree:

Living?

___ Married ___ Mother ___ Father

___ Divorced

___ Separated ___ Other

___ Widowed

Please list the names of any siblings attending university:

Name of Sibling Institutions Attending Degree Dates

1. 2. Extracurricular Activities 1. 2. 3. 4. Work Experience Please list any jobs or volunteer experiences that you have held during the past three years, including summer employment: Position Employer City Dates Hours/week Salary/week (USD) 1 2 3 4

Academic Honors / Awards / Scholarships / Exchange Programs

The purpose of this exercise is to a) help you determine and articulate what you believe makes you unique from the other applicants, b) help you identify your areas of interest and strengths so that you are prepared to begin researching undergraduate degree programs

Write a short essay In English of up to 500 words answering the question: Why are you interested in Competitive College Club? What makes you a good candidate for this club and for U.S. higher education?

Signature
I certify that the information in this form is accurate to the best of my knowledge: Printed Name: Signature: Date: