**APPLICATION FOR THE**

**2007**

**UNDERGRADUATE EXCHANGE PROGRAM**

**APPLICATION DEADLINE:**

**April 29, 2007**

**Please submit your applications and**

**Supporting documentation to the**

**Embassy of the United States of America in Cairo**

**Public Affairs Office/Cultural Section/ Exchanges**

**8 Kamal El Din Salah Street, Garden City, Cairo**

**or email: <CairoStudyUS@state.gov>**

![](media/image1.png){width="1.25in" height="1.25in"}

**A program of the**

**Bureau of Educational and Cultural Affairs**

**U.S. Department of State**

*Please provide all answers in English.*

**NAME**

Please print your name clearly **[exactly]{.underline}** as it appears
on your passport.

*Last First Middle*

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

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**HOME COUNTRY CONTACT INFORMATION**

Permanent mailing address in your home country:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home telephone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Mobile telephone:

Fax number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-mail address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**PERSONAL DATA AND PASSPORT MATERIALS**

Sex: Male Female Date of Birth: Place:

#  Month/Day/Year City Country

Country of permanent legal residence:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Country of
citizenship:

**Please provide a clear photocopy of the photo/data info page of your
current Passport.**

**EMERGENCY CONTACT INFORMATION**

Please provide the names and contact information of individuals who
should be notified in case of an emergency.

In the United States:

*Name Relationship to you Street Address*

# City State ZIP Code Telephone Number E-mail address

In your home country:

####  Name Relationship to you Street Address

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

**NAME** (Please print your name here):

**FIELD OF STUDY**

Major Field of Study:

Minor Field of Interest:

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

What is the last full academic year of university study you have
completed (please check one below):

Final year of Secondary School 1^st^ year 2^nd^ year 3^rd^ year 4^th^
year

## REFERENCES/RECOMMENDATION LETTERS

Please identify the three (3) individuals who will be writing letters of
recommendation on your behalf. At least one should be from your
secondary school. Make sure these are people who know your academic and
personal 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 the institution(s) at which you are presently enrolled. **You must
attach official transcripts for undergraduate study and official results
of the general secondary school leaving exam.**

+----------+-----------+-----+-----+-----------+-----------+--------+
| **Ins    | **In      | *   |     | **Major   | **Degree  | *      |
| titution | stitution | *Da |     | Field**   | Received  | *Grade |
| Name**   | L         | tes |     |           | and Date  | Point  |
|          | ocation** | A   |     | **of      | Rec       | A      |
| **(No    |           | tte |     | Study**   | eived\*** | verage |
| abbrevia | **(City,  | nde |     |           |           | \*\*** |
| tions)** | C         | d** |     |           |           |        |
|          | ountry)** |     |     |           |           |        |
|          |           | *   |     |           |           |        |
|          |           | *MM |     |           |           |        |
|          |           | /YY |     |           |           |        |
|          |           | --  |     |           |           |        |
|          |           | M   |     |           |           |        |
|          |           | M/Y |     |           |           |        |
|          |           | Y** |     |           |           |        |
+----------+-----------+-----+-----+-----------+-----------+--------+
| Primary  |           | Fr  | To: |           |           |        |
| School:  |           | om: |     |           |           |        |
+----------+-----------+-----+-----+-----------+-----------+--------+
| S        |           | Fr  | To: |           |           |        |
| econdary |           | om: |     |           |           |        |
| School:  |           |     |     |           |           |        |
+----------+-----------+-----+-----+-----------+-----------+--------+
| Post-S   |           | Fr  | To: |           |           |        |
| econdary |           | om: |     |           |           |        |
| Ed       |           |     |     |           |           |        |
| ucation: |           |     |     |           |           |        |
|          |           |     |     |           |           |        |
| (Uni     |           |     |     |           |           |        |
| versity) |           |     |     |           |           |        |
+----------+-----------+-----+-----+-----------+-----------+--------+

\* 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 indicate the date (month and year) you expect to
receive it.

\*\* Please indicate your Grade Point Average (GPA) according to the
system used at the institution at which you studied. Do *not* convert
your GPA to the U.S. educational system's equivalent.

Please explain any gaps in your education:

Have you ever been dismissed from a school or university? No Yes If yes,
please explain why?:

**NAME** (Please print your name here):

**LANGUAGE PROFICIENCY**

Native language(s):

Number of years of English study:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Where studied:

Knowledge of foreign languages, including English (Rate your abilities
as Excellent, Good, or Fair):

  ----------------- ----------------- ----------------- -----------------
  **Language Name** **Reading         **Writing         **Speaking
                    Ability**         Ability**         Ability**

                                                        

                                                        

                                                        
  ----------------- ----------------- ----------------- -----------------

**STANDARDIZED ENGLISH TEST SCORES**

**(You must provide a TOEFL® or ITP score report with this
application)** Please indicate your TOEFL® or ITP scores.

  ----------------------- ----------------------- -----------------------
  **Test Name**           **Date taken or to be   **Score**
                          taken**                 

  TOEFL®                                          

  ITP                                             

  OTHER                                           
  ----------------------- ----------------------- -----------------------

**NON-ACADEMIC ACTIVITIES**

Please list other community service, internships/jobs, sports or
cultural activities in which you have participated regularly in the past
two years. If you were a team leader, council member or other officer in
any institution or activity, please note that as well.

+----------------------+-------------------------------+------+-------+
| **                   | **Type of Activity**          | **D  |       |
| Location/Institution |                               | ates |       |
| and Contact**        |                               | of   |       |
|                      |                               | Par  |       |
|                      |                               | tici |       |
|                      |                               | pati |       |
|                      |                               | on** |       |
|                      |                               |      |       |
|                      |                               | **M  |       |
|                      |                               | M/YY |       |
|                      |                               | --   |       |
|                      |                               | MM/  |       |
|                      |                               | YY** |       |
+----------------------+-------------------------------+------+-------+
|                      |                               | F    | To:   |
|                      |                               | rom: |       |
+----------------------+-------------------------------+------+-------+
|                      |                               | F    | To:   |
|                      |                               | rom: |       |
+----------------------+-------------------------------+------+-------+
|                      |                               | F    | To:   |
|                      |                               | rom: |       |
+----------------------+-------------------------------+------+-------+
|                      |                               | F    | To:   |
|                      |                               | rom: |       |
+----------------------+-------------------------------+------+-------+

**NAME** (Please print your name here):

**Physical Challenges/Disabilities**

Please describe any physical disabilities you might have. If you require
any special equipment or medical treatment as a result of the physical
disabilities, please describe it. This information is gathered for
statistical purposes and to ensure appropriate placement. The program
does not discriminate on the basis of race, color, religion, sex,
national origin, and/or physical disabilities.

**Family Background**

Please complete the following regarding your family:

Father's Name:

Occupation:

Highest level of education attained:

None Number of primary school years\_\_\_\_\_ Number of secondary school
years\_\_\_\_\_

Secondary Diploma Bachelor Degree Master Degree Ph.D.

Father's Employment: Employed Retired \_\_\_\_\_\_\_\_\_\_\_Year
Deceased \_\_\_\_\_\_\_\_\_\_\_ Year

Mother's Name:

Occupation:

Highest level of education attained:

None Number of primary school years\_\_\_\_\_ Number of secondary school
years\_\_\_\_\_

Secondary Diploma Bachelor Degree Master Degree Ph.D.

Mother's Employment: Employed Retired \_\_\_\_\_\_\_\_\_\_\_Year
Deceased \_\_\_\_\_\_\_\_\_\_\_ Year

Number of siblings in your immediate family: Number of Brothers: Number
of Sisters:

## HOW did you find out about the NEA-SA Undergraduate Exchange Program? Please check all that apply.

The American Embassy Advising Office or other Embassy contact

From a friend From a relative From a teacher or professor

From an advertisement or notice *(Please specify the location)*:

Other *(Please specify how)*:

**NAME** (Please print your name here):

**UNITED STATES/ ABROAD EXPERIENCE**

Please describe any previous travel or study in the United States or any
other country.

+----------+----------+----------------------------------+-----------+
| **Travel |          | **Travel Purpose**               | **US      |
| Dates**  |          |                                  | Gov       |
|          |          | **(e.g. vacation, school,        | ernment** |
| **MM/YY  |          | etc.)**                          |           |
| --       |          |                                  | *         |
| MM/YY**  |          |                                  | *Program? |
|          |          |                                  | Y/N**     |
+----------+----------+----------------------------------+-----------+
| From:    | To:      |                                  |           |
+----------+----------+----------------------------------+-----------+
| From:    | To:      |                                  |           |
+----------+----------+----------------------------------+-----------+

**WORK EXPERIENCE** *(if applicable)*

Please start with your most recent position. You may include volunteer
activities and internships.

+----------------------+-------------------------------+-------+-------+
| **Name of Employer   | **Your Job Title and          | **    |       |
| and**                | Responsibilities**            | Dates |       |
|                      |                               | of    |       |
| **Location**         |                               | Em    |       |
|                      |                               | ploym |       |
|                      |                               | ent** |       |
|                      |                               |       |       |
|                      |                               | **    |       |
|                      |                               | MM/YY |       |
|                      |                               | --    |       |
|                      |                               | MM    |       |
|                      |                               | /YY** |       |
+----------------------+-------------------------------+-------+-------+
|                      |                               | From: | To:   |
+----------------------+-------------------------------+-------+-------+
|                      |                               | From: | To:   |
+----------------------+-------------------------------+-------+-------+

**NAME** (Please print your name here):

**ESSAY: Personal Statement---350 -- 500 words, typed.**

If you are completing a computer application, please insert your essay
responses below the appropriate essay question. If you are completing a
paper application, please type your essay responses on separate sheets
of paper and attach them to your completed application. Please describe
yourself and write a clear and detailed description of your academic
objectives and the reasons why you wish to pursue them in the USA.
Discuss your goals both in terms of your field of study and your own
personal development. Describe the type of program you wish to pursue in
the USA and how it relates to your academic background and interests and
your objectives for the future. The essay is an essential part of the
selection process and of your application for placement into an
appropriate program. Be sure to include any details that highlight your
personality and individuality.

**GRANT SUSPENSION/TERMINATION/REVOCATION**

*A grant may be revoked, terminated, or suspended.*

*Grounds for revocation or termination include, but are not limited to:
(1) violation of any law of the United States or the host country; (2)
any act likely to give offense to the host country; (3) failure to
observe satisfactory academic or professional standards; (4) physical or
mental incapacitation; (5) engaging in any unauthorized income-producing
activity; (6) failure to comply with the grant's terms and conditions;
(7) material misrepresentation made by any grantee in the application
form or grant document.*

*A grant may be suspended if: (1) the grantee ceases to carry out the
project or academic program during the grant period; (2) the grantee
leaves the host country without authorization of the Commission/post or
supervising agency; (3) conditions in the host country require the
departure of the grantee for reasons of personal safety or security.*

**SIGNATURE**

By my signature, I certify that, to the best of my knowledge, the
information provided in my application is accurate and complete, and
that I intend to return to my home country upon completion of my studies
in the United States. I also authorize any school or university which I
have attended or will attend to release my transcripts and any report to
the designated placement agency.

Signature:
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**NAME** (Please print your name here):

**CHECKLIST FOR COMPLETE APPLICATION:**

Before submitting your application to the address on the front page,
please be sure you have included all of the following REQUIRED
components:

> \_\_\_Completed, signed Undergraduate Exchange Program application
> form
>
> \_\_\_Personal statement in English, 350-500 words, typed
>
> \_\_\_Copy of the data/photo pages of your passport
>
> \_\_\_Official transcripts for years of university study
>
> \_\_\_Official results of the national general secondary school
> leaving exam

\_\_\_Three letters of recommendation from teachers/professors,
including one from the candidate's secondary level institution.

> \_\_\_TOEFL or ITP score report
>
> \_\_\_Two passport-size photos