PERSONAL INFORMATION Full legal name as it appears on your passport:
Preferred Mailing Address:
Work Address Home Address Street Address 1:
Street Address 2:
Work Phone (including country code):
Work Fax (including country code):
Cell Phone (including country code):
EDUCATION AND EMPLOYMENT What is the highest degree you have earned?
When was this degree awarded?
From which University?
Duration of Current Employment:
You may cut and paste from any Word document.
Do you have any physical difficulties that require special accommodations during the 2015 Mini-Course in Public Diplomacy? If
yes, please explain: Do you have any dietary restrictions?
Vegetarian/Vegan Gluten Free Dairy Free
PROGRAM FEES Please select your option:
A discount is available to organizations who send two or more participants. Please contact
Stacy Ingber for more information on group discounts.
MEDIA RELEASE I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.
I verify that I am the person identified on this form and that all of the above information about me is correct.