MAUREEN MANSFIELD WOMEN’S EMPOWERMENT SERIES:TRILATERAL YOUTH EMPOWERMENT PROGRAM* Please include all information in English

Applicant Information
Name (as it appears in proof of identification): _____________________________________
Preferred Name (if different): __________________________________________________
Age: __________ Date of Birth (Month/Day/Year): __________________ Pronouns: ________Country of Citizenship: _______________________If you hold citizenship or permanent residency in any other country, please list here (optional): ________________
Race (optional): __________________
Home Address: _________________________________________________________________
Phone/Mobile Number: ____________________
Email Address: _____________________________
Optional: Please list social media platforms that you utilize frequently and provide your social media
handles, if you’d like. (e.g. LinkedIn, Facebook, TikTok, Instagram, Twitter, blog, etc.)

The Maureen and Mike Mansfield Foundation provides equal opportunities to all program
participants and prohibits any type of discrimination on the basis of race, color, religion, genderassigned at birth, disability status, genetics, or sexual orientation. The Foundation will do its best toprovide reasonable accommodations for disabilities.

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Do you have any conditions that might restrict your mobility or require accommodations/services
while abroad? ☐Yes
☐NoIf yes, please indicate and specify in the box below:☐Hearing☐Medical☐Mobility☐Speech☐Visual☐Other, please specify _______________________________________________

Education & Related Experiences
Education Level: what’s the highest level of education/degree have you achieved?
☐ High School Diploma☐ Bachelor’s Degree☐ Currently enrolled in an undergraduate program☐ Currently enrolled in a graduate program

Name of the institution that you are currently attending or recently graduated from:________________________________________________________________________
Grade Point Average (GPA)*: _____________*GPA, or Grade Point Average, is a number commonly used in US universities to indicate how high a student scoredin their courses on average. Using a scale from 1.0 to 4.0, each letter grade is assigned a number (A=4, B=3, C=2,D=1, F=0). If you need assistance with calculating your GPA, please contact your University’s Registrar orAcademic Affairs office.
Please provide the maximum GPA that your university uses: _____________
Relevant Coursework: please list any coursework that you believe is relevant to the program.

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Please list below relevant leadership experiences and extracurricular activities including volunteer
work, training, workshops (optional).

Language Proficiency & Experiences Abroad
Please indicate your native language: __________________
Please mark your English proficiency below if English is not your native language.
Listening/Reading☐ Beginner (A1/A2)*☐ Intermediate (B1/B2)*☐ Advanced (C1/C2)*

Speaking☐ Beginner (A1/A2)*☐ Intermediate (B1/B2)*☐ Advanced (C1/C2)*

Writing☐ Beginner (A1/A2)*☐ Intermediate (B1/B2)*☐ Advanced (C1/C2)**Language levels are based on the Common European Framework of Reference (CEFR). Please
review the self-assessment grid carefully to indicate your English proficiency.
Please provide any English language test score(s) such as TOEIC/TOEFL, Cambridge, IELTS, etc.
(optional) _________________________________

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If you speak other languages such as Japanese, Korean, Spanish, French, etc., please list them here.
For each language, please indicate the level as Beginner, Intermediate, or Advanced.

Please list experiences abroad (when, where, and for what purpose).
e.g., May - June 2018

e.g., Thailande.g., study, volunteer program, tourism

Topic Interests
Applicants will be assigned to multinational teams with the objective to create a youth perspective
policy recommendation on a specific topic. Please rank the below topics from 1-7 with 1 being thetopic of highest interest and 7 being the topic of lowest interest. This will be used to help withmatching applicants to the appropriate mentor and teammates.
___ Climate Change___ Economic Growth___ Information and cybersecurity___ Regional Security Issues___ Marginalized Populations (e.g. LGBTQ+, people with disabilities, refugees, etc.)___ STEM___ Women and Girls Empowerment___ Other: if you are interested in other topics, please list them here:4

Emergency Contact Information
Contact #1
Name: ___________________________
Relationship to Applicant (i.e., mother, father, guardian, partner, etc.): __________________
Phone Number: _________________________ Email ______________________________
Contact #2
Name: ___________________________
Relationship to Applicant (i.e., mother, father, guardian, partner, etc.): __________________
Phone Number: _________________________☐

Email ______________________________

I have voluntarily provided the above contact information and authorize the Maureen andMike Mansfield Foundation to contact any of the above on my behalf in the event of anemergency.

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Short Essays
Applicants are required to complete both Part 1 and Part 2 in English.
PART 1: Motivation Statement (200-300 words)
In the space below, please explain:• Why you are interested in the program• What you would like to learn from the program• Why you would be a good addition to the program• How this program contributes to your future aspirations

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PART 2: Topic Statement (maximum 500 words)
Considering the topic options from page 4 of the application, please choose one topic and write aresponse covering why you are interested in the topic, why you believe it is important, andyour proposed solutions to the topic issues.

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Recommendation Letter Information
Applicants are required to provide one or two recommendation letters (educational and/orprofessional). Letters must be submitted to applications@mansfieldfdn.org no later than 5:00 p.m.
(U.S. Eastern Standard Time) on January 10, 2023.
Below, please provide name and contact information for the person or people writing a
recommendation letter. Please note that the Mansfield Foundation will not send recommendation
letter requests. This must be requested by the applicant.

Recommendation Letter #1
Name: ___________________________
Relationship to Applicant (i.e., professor, supervisor, etc.): __________________
Phone Number: _________________________ Email ______________________________
Recommendation Letter #2
Name: ___________________________
Relationship to Applicant (i.e., professor, supervisor, etc.): __________________
Phone Number: _________________________

Email ______________________________

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Information Confirmation and Sharing Agreement Statement☐☐☐☐

I hereby declare that the information provided is true and correct. I also understand that any
willful dishonesty may be grounds for disqualification of my application or immediate
termination of participation in this program.
If this application is successful, I understand that my attendance and participation will berequired at monthly virtual workshops and bi-monthly virtual mentor check-in meetings.
If this application is successful, I acknowledge that travel to Washington D.C. for a 5-day,
4-night in-person capstone event is required for this program.
I authorize the Maureen and Mike Mansfield Foundation to keep this information in its
program files. I authorize the Maureen and Mike Mansfield Foundation to disclose in aconfidential manner any information supplied in this application for assessment andprogramming.

Do you wish to provide details of circumstances or qualifications not reflected in the application?
(optional)

Applicant Signature: _______________________________

Date: __________________The Maureen Mansfield Women’s Empowerment Series: Trilateral Youth Empowerment Program is sponsored bythe U.S. Department of State with funding provided by the U.S. Government with support from the Maureen andMike Mansfield Foundation.

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