| PERSONAL INFORMATION |
Full legal name as it appears on your passport:
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| Preferred Mailing Address:
Work
Home |
Street Address 1:
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Street Address 2:
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City:
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State/Province:
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Country:
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Postal Code:
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Work Phone (including country code):
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Work Fax (including country code):
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Cellphone (including country code):
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Work Email Address:
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Alternate E-mail Address:
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Sex: M or F:
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Date of Birth (mm/dd/yy):
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Birthplace (City, Country):
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Citizenship:
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| EDUCATION AND EMPLOYMENT |
What is the highest degree you have earned?
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Date awarded:
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From what University?
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What is your current place of employment?
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Duration of current employment:
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Job Title:
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Biography:
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Resume:
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| VISA INFORMATION |
If you are not a U.S. citizen, permanent resident, or have not been granted political asylum, you will need a J-1 exchange visitor visa to attend the Summer Institute. If you need a visa, CPD will send you a DS-2019 form to begin visa application process.
Please check one of the items below:
I need a DS-2019 Form for a J-1 visa.
I do not need a DS-2019 Form. I have a valid visa.
I do not need a visa. |
HOUSING REQUEST [ Radisson Hotel ]
Accommodations are provided at the Radisson Hotel located across the street from the USC campus. Reservations are made for 13 nights at rate of US$ 120/night plus taxes. Total hotel cost will be US$ 1560 plus taxes. Lodging costs are not included in tuition fees.
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| HOUSING |
Yes, I need housing
No, I will make my own housing arrangements |
MEAL PLAN
A meal plan can be purchased for $250. The meal plan is valid only at on-campus venues.
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| MEAL PLAN
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Yes, I would like to purchase a meal plan for $250
No, I would not like to purchase a meal plan |
Do you have any physical difficulties that require special accomodations? If so, please explain what special accomodations you will need in the space below:
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| PROGRAM FEES |
| Please check one box:
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How did you hear about the Public Diplomacy Summer Institute?
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| I verify that I am the person identified on this form and that all of the above information about me is correct |
