2010 United States-Syria

Grassroots Diplomacy Program

INSTRUCTIONS: Please fill in the following form completely. When you have
finished, “SAVE AS” and title the document, “LAST NAME, First Initial +
FORM,” (i.e. SMITH, J Form).

IN ONE E-MAIL, send this completed application form along with Essay A, Essay
B, and your resume (optional) to: grassrootsdiplomacy@amln.org.

DEADLINE FOR SUBMISSION: June 11, 2010

A. PERSONAL INFORMATION
LAST NAME: FIRST NAME:
           
DATE OF BIRTH (mm/dd/yy): GENDER: SOCIAL SECURITY NO.:
      M F    -  -    
(OPTIONAL) ETHNICITY: (Please Type)      

B. CONTACT INFORMATION
CURRENT MAILING ADDRES:
     
CITY: STATE: ZIP CODE:
                 
PHONE NO.: E-MAIL ADDRESS:
   -   -          
CURRENT ADDRESS VALID UNTIL (mm/dd/yy):      

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 2010 United States-Syria
C. EMERGENCY CONTACT INFORMATION
LAST NAME: Grassroots Diplomacy
FIRST NAME: Program
           
RELATIONSHIP TO STUDENT: WORK PHONE NO.: CELL PHONE NO.:
         -   -        -   -    
HOME PHONE NO.: E-MAIL ADDRESS:
   -   -          
ADDRESS:
     

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 2010 United States-Syria
Grassroots Diplomacy Program
E. EXTRACURRICULAR ACTIVITIES, JOB EXPERIENCE, HONORS/AWARDS
and DATES
In the space below, please BRIEFLY list and describe your extracurricular activities and position/title,
job experience, awards or honors you have received, and all corresponding dates. Fill this section
out even if you intend to send a resume.
1.      
2.      
3.      
4.      
5.      
6.      
7.      
8.      
9.      
10.      
Etc:      

D. EDUCATIONAL BACKGROUND
DEGREES
DATES EXPECTED
INSTITUTION FIELD OF
ATTENDED OR GPA:
ATTENDED STUDY:
(mm/yy) RECEIVED
:
From – To: AND DATE
(mm/yy):
           -      Degree:       Major:      Major:     
Date:       Minor:       Cumulative:      
           -      Degree:       Major:      Major:     
Date:       Minor:       Cumulative:      
           -      Degree:       Major:      Major:     
Date:       Minor:       Cumulative:      

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 2010 United States-Syria
Grassroots Diplomacy Program
F. LANGUAGE BACKGROUND
PLEASE GIVE A SELF-APPRAISAL OF YOUR COMPETENCE IN ARABIC (MODERN
STANDARD)
YEARS OF FORMAL STUDY:      
SPEAK: COMPREHEND: READ: WRITE:
Select Select Select Select
OTHER LANGUAGES STUDIED:       LEVEL OF PROFICIENCY: Select

G. RECOMMENDATION INFORMATION
NAME OF RECOMMENDER: INSTITUTION:
           
TITLE: RELATIONSHIP TO YOU:
           
Please provide a letter of recommendation from an academic reference. Send this letter in a signed,
sealed envelop to:
AMERICAN MIDEAST LEADERSHIP NETWORK
2010 UNITED STATES-SYRIA GRASSROOTS DIPLOMACY PROGRAM
P. O. BOX 2156
LONG ISLAND CITY, NY 11102

H. ADDITIONAL INSTRUTIONS

Please make sure to arrange for the AMLN to receive an official transcript from your college or
university at the above listed mailing address.

After you have completed this form, be sure to download and complete Essay A and Essay B, both
available on the AMLN Web site.

If you have any further questions regarding your application or the program, please contact AMLN
President Rami Nusseir at rami@amln.org or at .

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