Th omas Jefferson Scholarship Program's 2015-2016 Tunisia Undergraduate Scholarship Program

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Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
(Tunisia UGRAD)
Supplemental Application Form
1. What is the name of your current Faculty/School/Institute at your university? _______________________
_________________________________________________________________________________________
•
With which university is your Institute/School affiliated? _______________________________________
•
In what city do you study? __________________________________________________________________
2. What is the education level of your father?*
Primary/Middle School (1-9 years)
Secondary School (10-13 years)
University Degree
Masters or Higher
University Degree
Masters or Higher
3. What is the education level of your mother?*
Primary/Middle School (1-9 years)
Secondary School (10-13 years)
*The responses to these questions will neither disqualify applicants nor guarantee selection.
4. Do you have a passport?
Yes
No
If yes, what is the expiration date (mm/dd/yyyy)? ________________________________________________
5. Have you ever received a J-1 visa?
Yes
No
If yes, list the dates showing exact duration of stay in the United States on a J-1 visa (mm/dd/yyyy to mm/dd/yyyy).
6. Have you ever been in the United States for any other reason?
Yes
No
If yes, list the dates showing exact duration of stay in the United States (mm/dd/yyyy to mm/dd/yyyy) and the reason for
travel.
7. How did you first learn about the Tunisia Undergraduate Scholarship Program? Please check only one.
Academic Advisor
American Corner
Conference Booth
Educational Advising Center
Electronic Listserve
Friend/Colleague
Fulbright Commission
Facebook/Internet
IREX and/or CEMAT
Lecture/Presentation
Newspaper
Advertisement
Program Alumni
Radio
Television
University faculty/staff
U.S. Embassy
Other (please specify)
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
NAME:
HOME CITY:
DATE OF BIRTH:
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
8. Are you applying to any other sponsored educational exchange program for the 2015-2016 academic year?
Yes
No
If yes, please specify program:
Name of sponsoring organization:
9. What was your primary city of residence in the last 10 years? (i.e. where your parents live) _____________________
10.
What is the approximate population of that city? ___________________________________________________
11.
In which governorate of Tunisia is that city located? (please circle)
Ariana
Béja
Ben Arous
Bizerte
Gabès
Gafsa
12.
Jendouba
Kairouan
Kasserine
Kebili
Kef
Mahdia
Manouba
Medenine
Monastir
Nabeul
Sfax
Sidi Bouzid
Siliana
Sousse
Tataouine
Tozeur
Tunis
Zaghouan
How long did this application take you to complete?
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
SHORT ANSWERS
Please provide short answers of no more than 250 words each addressing the following prompts. Note: Your short
answers must be your own work. If your short answers are found to be plagiarized (using someone else’s words and
claiming them as your own), your application will be disqualified.
1.
Please describe a time when you worked with someone from a different background or culture, and had to
negotiate a solution to a misunderstanding or conflict based on your differences. What happened and how did
you resolve the situation?
2.
Please describe your past community engagement and volunteering experience. What motivated you to do this
work?
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
3.
Please describe how you plan to positively contribute to Tunisia’s economic development as a young
professional during the next 5-10 years.
4.
Please describe a time that something you planned did not work out as you had hoped. What did you learn from
that disappointing experience?
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
ESSAY #1:
Please attach an essay in English of no more than 1000 words addressing the following questions. Note: Your
essay must be your own work. If your essay is found to be plagiarized (using someone else’s words and claiming
them as your own), your application will be disqualified.
Essay #1: A global citizen is a well-rounded individual, who contributes positively to their community, country, and the
world and serves as a role model for others.

How have you been a global citizen in the past?

How do you plan to be an active global citizen in the future?

What are your (a) academic, (b) professional, and (c) personal goals for your growth as a global citizen?

How will participating in this program help you achieve your global citizenship goals?
Please answer all questions in your essay below.
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
CONTINUED ESSAY #1:
Please use the space below to continue your response to Essay #1.
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
ESSAY #2:
Please attach an essay in English of no more than 1000 words addressing the following questions. Note: Your
essay must be your own work. If your essay is found to be plagiarized (using someone else’s words and claiming
them as your own), your application will be disqualified.
Essay #2: Please describe a time that you undertook a school project, community activity, or other
initiative. How does this experience demonstrate your potential for innovative and/or entrepreneurial leadership?
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
CONTINUED ESSAY #2:
Please use the space below to continue your response to Essay #2.
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
NAME:
HOME CITY:
DATE OF BIRTH:
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
IREX Privacy Policy Statement and Application Certification
Your privacy is important to IREX. That is why we request that all applicants read the following privacy policy statement
carefully.
1. APPLICANT AND P ARTICIPANT INFORMATION CONTENT AND STORAGE
Information about program applicants and current and past participants consists of data contained in their
applications, information derived from interviews, and information gathered during the course of their program and
as program alumni. IREX stores this information in written and electronic form indefinitely. Some data, such as
contact information and professional experience, is continually updated.
2. USE OF INFORMATION
Information, which is described above, may be:
A.
B.
C.
D.
Used by selection committees and interviewers to review applicants;
Supplied to the program’s funding organization;
Submitted to potential host schools, universities, or organizations and/or organizations that provide internship
opportunities;
Used for the evaluation of an individual’s participation in the program and in the collection of data for general
program evaluation by IREX, funding agencies or other organizations contracted to conduct evaluations.
IREX does not sell applicant or current/past participant information.
The principles stated herein are binding only to IREX; other organizations involved in the administration of these
programs may adhere to other policies.
3. CERTIFICATION: I certify that I completed this application myself, without any aid or assistance, that the
information given in this application is complete and accurate, and that I have carefully read and understand all
notes and disclaimers provided therein.
I understand that IREX reserves the right to verify all the information listed in the application. I understand
that giving false or misleading information in the application will result in exclusion from the competition or
immediate dismissal from the Tunisia Undergraduate Scholarship Program (Tunisia UGRAD).
Also, I acknowledge that I am aware of the following requirements that I must observe if I am selected for the program:
• I must abide by all program rules and regulations and observe all the laws of the United States during my stay
there, including returning to my home country for at least two years at the conclusion of the program in
compliance with J-1 visa requirements.
• The medical insurance provided to me during my travels is intended only for emergencies and does not
cover ordinary, pre- existing, or dental conditions.
• My spouse, children, or other relatives or individuals are not permitted to accompany me to the United States on the
program.
Sign below. If you are submitting your application online, you are signing this document by typing
your name.
Signature of applicant
Date
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
NAME:
HOME CITY:
DATE OF BIRTH:
Please list your additional coursework if you did not have sufficient space in application Part 1.
ACADEMIC YEAR
(for example 2013-2014)
SUBJECT / COURSE
(class title)
GRADE
(Mark, Score)
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time
Thomas Jefferson Scholarship Program's
2015-2016 Tunisia Undergraduate Scholarship Program
ACADEMIC YEAR
(for example 2013-2014)
SUBJECT / COURSE
(class title)
NAME:
HOME CITY:
DATE OF BIRTH:
GRADE
(Mark, Score)
A program sponsored by the Bureau of Education and Cultural Affairs (ECA)
of the United States Department of State, supported by the people of the United States, and implemented by IREX.
This Application is free and may be duplicated. Apply online at ww.irex.org.
Application Deadline: Monday, December 15, 2014 at 5:00 pm Tunis time

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