Form DS-7005 Global Undergraduate Exchange Program Application

U.S. Department of State

OMB APPROVAL NO. 1405-0138
EXPIRATION DATE 11/30/2011
ESTIMATED BURDEN: 45 MINUTES*

PARTICIPANT APPLICATION
2011-2012 GLOBAL UNDERGRADUATE EXCHANGE PROGRAM
1. Name (As Written on Official Documents)

(Middle Name)

(First Name)

(Family Name)

2. Country or Countries of Citizenship
3. Country of Legal Residence
4. Place of Birth
(City or Town)

(Country)

5. Date of Birth
(Month)

6. Gender

Male

Female

7. Marital Status

Single

Married

(Day)

(Year)

Citizenship(s) of Spouse (If Applicable)

8. In order to respond to required U.S. Government inquiries, please check the box below, on a voluntary basis,
if you have the following disabilities:
Hearing Impairment

Speech Impairment

Learning Disorder

Other (Specify)

Visual Impairment (Legally Blind)

Orthopedic Impairment

9. Current Contact Information
Address Type:

Temporary Residence (Other Than Dormitory)

Dormitory

Permanent Residence

Street/Building Number

Apartment

City

Postal Index

Region

Country

Telephone

(

Fax

)

Cell Phone (If Applicable)

(

(

)

Email

)

10. Permanent Home Address (If Different from Current)
Street/Building Number

Apartment

City

Postal Index

Region

Country

Telephone

(

)

Cell Phone (If Applicable)

Fax
(

(

)

Email

)

Paperwork Reduction Act Statement
The information gathered is used by the U.S. Department of State's Bureau of Educational and Cultural Affairs (ECA) to inform program design,
management, and funding. The information collection activity involved with the program is conducted pursuant to the mandate given to the U.S.
Department of State under the terms and conditions of the Mutual Educational and Cultural Exchange Act of 1961, Public Law 87-256.
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do
not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington,
DC 20522-2202.
DS-7005
01-2011

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11. Work Address (If Applicable)
Name of Business
Title/Position
Street
City

Postal Index

Country

Telephone

(

)

Fax

(

)

12. Educational Background In the table below, please list all universities, institutes, and special academic programs you have attended or
are currently attending, with the most recent listed first. Transliterate directly from your native language into English spelling all words pertaining
to your education. Do not use American equivalents unless you hold a degree from a U.S. academic institution.

Example
Institution and City

Department

Dates (Month-Year)

Type of Degree

Date Degree Received
or Expected

Moscow State University,
Moscow

Department of
Journalism

August 1990 May 1995

Diploma

May 1995

Institution and City

Department

Dates (Month-Year)

Type of Degree

Date Degree Received
or Expected

13. Testing If you have not taken the Test of English as a Foreign Language (TOEFL), Graduate Records Examinations (GRE), or the Graduate
Management Admission Test (GMAT) and are selected as semi-finalist, you may be required to take the TOEFL and GRE or GMAT (business
administration applicants) exams. The cost of these examinations will be covered by this program.
If you have previously taken any of the above-mentioned examinations, please give your score and the date and place where you took the
examination. Attach a copy of your score report to the application if available. If selected, you may be required to submit official test results via
ETS directly to the programming agency.

TOEFL Score

Date (mm-dd-yyyy)

Location

GRE Score

Date (mm-dd-yyyy)

Location

GMAT Score

Date (mm-dd-yyyy)

Location

I have not taken the TOEFL, GRE, GMAT examination.

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14. University Courses List below, in English, all the university courses you have taken, and the grades you received. First-year students
should list their current university courses followed by their 11th form courses and final grades.
Attach additional pages if necessary. Describe the grading system used (example: "5"= excellent to "1"=failing, "A"= excellent to "F"= failing):
Academic Years (for example, 2004-2005)

Subject/Course (Class Title)

Grade

15. Native Language Contact Information
Native Language is

.

During the selection process, it may be necessary for one of our offices to contact you. To assist our offices in maintaining accurate records,
please complete the following section in your native language.

Name
(Family Name)

(First Name)

Street/Building Number

(Middle Name)
Apartment

City

Postal Index

Country

Region

Please complete the following information in your native language with either your current academic institution information or employer
information, whichever is currently applicable:
Current Academic Institution/Employer
Department/Position
Dean or Academic Advisor/Supervisor Name
Dean or Advisor Telephone

(

Emergency Contact Name

)
Relationship

Emergency Contact Address
Emergency Contact Phone/Fax/Email

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16. Proposed Field of Study in The U.S. Please indicate one specialization that most closely matches your current specialization from
the list of eligible fields available in the application instructions.
If selected as a finalist, applicants may not change their field of study during the program.
Proposed Field

17. Current Academic Institution
FACULTY/DEPARTMENT
Street
City

Postal Index

Country

18. Present Course Year:

Telephone

First

Second

(

)
Third

Fax

(

)

Fourth

19. Expected Graduation Date (month/year)
20. Current Specialization/Major in Home Country
21. Previous VISA Information
a. Have you previously traveled on a U.S. Government-sponsored or other U.S. exchange program?

Yes

No

If yes, please complete the following:
Name

Year(s)

Location in the U.S.
(City)

b. Have you ever received a U.S. J-1 Visa?

(State)
Yes

No

If yes, list dates showing exact duration of stay in the United States on a J-1 visa (month-day-year - month-day-year).

c. Have you ever received a U.S. F-1 Visa?

Yes

No

If yes, list dates showing exact duration of stay in the United States on a F-1 visa (month-day-year - month-day-year).

d. Have you been in the U.S. for any other reason?

Yes

No

If yes, please list the duration of stay in the United States, except for visits to the United States as a tourist (month-day-year - month-day-year).

22. Extra-Curricular Activities Please list all volunteer positions, work experience, awards, and leadership positions you have
held within the past four years.

23. How long did it take you to answer this survey?
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minutes.
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