Nominating Organization:
The application consists of 11 pages. Page 2 is to be completed by the nominating organization. Pages 3-11 are to be completed by the nominating organization’s candidate in block letters. Please return the completed application in MSWord format to the US Embassy in Ulaanbaatar. Include signed and scanned copies of the final two signature pages with your completed application.
Application Instructions:
To be completed by the NOMINATING ORGANIZATION
Full Name: (nominator)
Place of work/position:
From whom did you receive this application form?
Your telephone number:
Additional phone number:
Fax number:
Email address:
I nominate the following person (full name):
Recommendation.
Your recommendation is required by the selection committee in order to understand your position as the nominator. Explain why, in your view, the applicant should take part in the Open World Program.
Please write about the achievements of your applicant in his/her professional activities, relating to the theme of the program. The recommendation can be written in Mongolian or English.
____________________________________________ _________________________
Signature of Nominator Date
Theme:
Social Issues/Healthcare Primary and Secondary Education
Local governance Other________________________
To be completed by the APPLICANT
Last Name:
First and Middle Name:
Date of Birth:
Day
Month
Year
1. PLACE OF PERMANENT RESIDENCE (AS INDICATED IN PASSPORT)
City/Town/Municipality:
Region:
Code:
Street Address:
2. CONTACT MAILING ADDRESS
Name of Contact, Company, Organization:
3. CONTACT INFORMATION
Home Telephone No. (with area code):
SKYPE:
Cell Phone No. (with area code):
Other Number:
E-mail Address No. 1:
E-mail Address No. 2:
4. ADDITIONAL PASSPORT INFORMATION
(Please include a photocopy of your passport.)
Passport No.:
Ser.
№
Expiration Date:
PLACE OF BIRTH AS IT APPEARS IN YOUR PASSPORT
City of Birth:
Country of Birth:
Please list other surnames used (for example: maiden name)
Marital Status:
single
married
divorced
widowed
5. Primary occupation, starting with current position
(Please do not use abbreviations)
Work Tel. 1:
(city code/number)
Work Tel. 2:
A) Present Occupation
Starting Date – (month/year) - Present
Name of organization:
Position and responsibilities:
Your Employer’s Website Address:
B) Previous place of work
Starting Date: (month/year)– Termination Date – ( month/year):
) C) Previous place of work
Position:
6. Information about Current Professional Activity for which you were Nominated for the Open World Program
(The questions below are included in order to obtain more detailed information about your professional activities and will help the local host organization d program content for your stay in the US.)
Give a short (2-3 sentences/ 5 lines maximum) description of the organization where you are currently employed and of your professional activity in this position:
Position of your direct supervisor:
Type of organization - please choose one from the following categories A through H and provide additional information as requested:
Regional Yes
Local No
Secondary educational institution
Institution of higher education
Other (please specify):_____________________________________________________________
Specialization:______________________________________________________________________
Note one of two:
out-patient clinic
in-patient clinic
Note one of three:
Commercial enterprise
Partially privatized enterprise
Public enterprise
Please specify the field:
Please specify:
How many people work in your organization?
How many subordinates do you have?
Less than 10 11-20 21-50 51-100 Over 100
In case you have a supervisor, how many subordinates does he/she have?
In case you have a supervisor, how many supervisors does he/she have?
0 1 2 3 Over 3
How long have you been working in this organization?
less than 1 year 1 to 5 years 6 to10 years Over 10 years
Please indicate the activities that are part of your main duties at work:
Artist
Attend political party meetings
Conduct economic development activities
Conduct international work
Conduct long-term planning/forecasting
Conduct needs assessments
Conduct training of staff or clients
Coordinate activities of multiple organizations
Develop or implement industry or organization standards
Engage in commercial activities
Give interviews
Journalist
Lobby government officials or legislators
Make public appearances
Manager in the field of arts
Perform data analysis
Perform financial or operational audits
Plan private industry production and distribution
Provide information to the public
Provide social/human services
Respond to public inquiries
Serve on a board of directors
Teach university students
Work in media
Work with databases
Work with public safety/emergency issues
Other (specify)
Attend meetings with govt. officials
Civil servant
Conduct fundraising activities
Conduct interviews
Conduct marketing/advertising activities
Conduct research
Conduct urban or regional economic planning activities
Coordinate or manage human resources
Draft legislation or policy statements
Gather and/or analyze public opinion
Give lectures
Land use planning
Make government/public policy decisions
Manage government organization
Meet with constituents
Perform evaluations of projects or work performed
Plan and/or monitor finances or budgets
Prepare economic analyses
Provide medical or health care services
Represent clients in legal matters
Serve as judge or judicial official
Teach school students
Work as activist or advocate on social issues
Work on an election campaign
Work with information technology
Write articles/press releases/reports/speeches
7. CURRENT CIVIC ACTIVITIES
(for example: judicial council, school council, civic organization, etc. Do not abbreviate.)
Responsibilities:
Start date (month/year):
Number of hours per month:
Is this a volunteer position unrelated to your primary work?
1.
Yes
No
2.
8. CURRENT WORK AS TEACHER/TRAINER
(not to be completed if your primary work is teaching or training)
9. CURRENT POLITICAL ACTIVITIES
(Please do not abbreviate.)
Name of political party/movement:
Responsibility:
10. ADDITIONAL LEGISLATIVE POSITIONS
Please indicate any position you have held in a legislative body, beginning with the most current position, which is not related to your current primary position. Do not use abbreviations
Level of government in which the you work or worked in a legislative body
Position Title:
Starting date
(month/year)
End date
Was this an elected position?
National
Regional
Local/Municipal
11. EDUCATION, PUBLICATIONS, GRANTS, and CONFERENCE PRESENTATIONS
Level of Education:
Uncompleted Secondary Education
General Secondary Education
Specialized Secondary Education
Uncompleted Higher Education
Higher Education
Candidate of Science
Doctor of Science
Knowledge of English (Knowledge of English is not part of the selection criteria. This information is needed for choosing a host family.)
None
I know a few words
Basic Conversation
Conversational
Fluent
Please list the other foreign languages that you do speak:
________________________
Last institution of higher education from which you graduated and area of specialization in you earned your degree:
A
Other educational institution where you studied no less than 2 years and graduated and area of specialization in which you earned your degree:
Please indicate the titles of your last three publications (books or articles) or radio/TV programs that you have created:
Place of publication, publisher, name of media outlet:
Date of publication or broadcast:
3.
Total number of publications:
Received grants:
Name 3 of the most significant projects from received grants
Grant given by:
Amount in US dollars:
Year Grant Received:
CONFERENCE PARTICIPATION
AS PRESENTER
Provide name of conference Topic
City/
Country
Name of presentation
Conference organized by:
RECOGNITION AWARDS
Indicate type (Award, Certificate, or Other):
Title
13. PERSONAL INFORMATION
Last name/First name/Middle name of emergency contact:
Emergency contact telephone number in Mongolia:
Relationship of emergency contact to the applicant:
Religion (optional question):
Would you object to attending religious services if attendance is a custom of your host family?
Yes, I would object No, I would not object
Are you a smoker? Yes No
Are you a vegetarian? Is there any food you avoid? If so, please specify. If you suffer from any food allergy/food intolerance, list the products that trigger your allergic reaction. Do you have any other dietary restrictions? If so, please specify.
Are you allergic to any pets or domestic animals and would they be an obstacle to your staying with a host family. If so, please specify:
Medical information about your physical health. This information will not affect the outcome of the selection process. Please describe any physical restrictions, allergies, or other conditions you have, including those requiring certain medications. This information is confidential and will be used only for the process of finding a host family and in the event of a medical emergency.
Full name of your spouse:
sons, age:_______________ daughters, age:________________
Please indicate briefly your interests and hobbies. (For example: playing guitar, swimming, collecting stamps, etc.)
Have you been to the USA before? Yes No
From
To
Type/class
Purpose of travel
(tourism, business, conference, education, other)
Name of country
Purpose of travel (tourism, business, conference, education, other)
Have you participated in a United States Government sponsored exchange program before?
Yes No
(if yes, list name of program and dates):
15. JOINT PROJECTS WITH AMERICAN ORGANIZATIONS
Have you participated in a professional or other joint project with American governmental, private, or non-profit organizations?
Yes, and I continue to participate
Yes, I have participated in the past
If you have answered “yes,” then please describe the project in 2-3 sentences.
16. ESSAY (not more than 10 sentences)
(Dear Candidate! Your answer will be read by the selection committee and may determine your participation in the program. If selected, the local host coordinator will use this information to tailor the community program for you.)
Please describe the main focus of your professional activity (this may be associated with your primary position or an additional position) for which you were nominated for the Open World Program. What knowledge and experience do you expect to acquire as a result of your participation in the program?
I certify that the information provided in this application is authentic. I understand that final approval of my candidacy for the program depends on the availability of and compliance with the conditions of my J-1 visa for participants of exchange programs. In accordance with the terms of the J-1 visa, I promise to return to my home country after finishing the program.
________________________________________ ___________________________
Signature Date
Candidate and program participant information is essential to the Open World Leadership Center to conduct the program, assess program quality and effectiveness, and to develop new related projects.
The Open World Leadership Center strictly adheres to principles of confidentiality of information received from candidates and program participants, and the information will be used according to the provisions set forth in this document. Key provisions of this document are valid only for the Open World Leadership Center. Other organizations involved in the administration of the program may adhere to this or a similar policy on candidate and program participant information.
1. Content and means of collecting information
The content of candidate and program participant information consists of facts received in completed applications, interviews, program participation and administration. This information may include personal information such as contact data and data on education, professional experience and employer organization.
The specified information is retained by the Open World Leadership Center in written and electronic formats. Some information, such as contact data, is updated in order for Center representatives to maintain contact with participants. This will allow participants to receive additional information about new programs and projects, and also to evaluate the effectiveness of programs sponsored by the Center.
The information is used:
Information about individuals, candidates, and program participants may also be used by the Open World Leadership Center, donors or authorized representatives for statistical and evaluative program research. Data analyzed for this purpose may be published only as statistical data. Personal data is not published. The exception is that information is shared with organizations that host for the program and with organizations that provide professional development opportunities, small grants, programs, and events for alumni. Materials provided by participants and alumni directly to the Center may also be published unless the Center is told explicitly not to publish these items.
By signing this document, you are consenting to the collection, use, storage, and dissemination of information about you in accordance with the terms set forth above.
______________________ _______________________________________________ ___________
Signature Last Name, First Name, Middle Name Date
Улсын Ерөнхий Прокурорын Газрын Олон нийттэй харилцах алба
