* 1. Full name

* 2. Date

* 3. Street Address

* 4. City

* 5. State

* 6. Postal Code

* 7. Phone

* 8. Email

* 9. Male/Female

* 10. Date of Birth

* 11. Age as of June 19, 2016

* 12. Name and City of Current Educational/Community Institution where you are Employed

* 13. City and Country of Birth

* 14. Country of Citizenship or Permanent Legal Residence

* 15. Education After High School

* 16. Degree Obtained

* 17. Do you speak any languages other than English?

* 18. Please list any teaching honors or awards you have received

* 19. Work Experience

* 20. Work Experience

* 21. Work Experience

* 22. Please describe one important problem facing your school, neighborhood or community today

* 23. How do you think you might help to address this problem?

* 24. Please describe any leadership roles you have taken in your school, neighborhood or community. How long have you been involved in these activities?

* 25. Why do you want to participate in the Indonesia-U.S. Youth Leadership Program?

* 26. How will participation in the Indonesia-U.S. Youth Leadership Program benefit your community?

* 27. Participants in this program will learn about leadership skills, conflict resolution, and cross-cultural awareness. Please describe why these issues are important to you.

* 28. Is there anything else you would like us to know about you?

* 29. Do you currently have a valid passport?

* 30. If yes, issuing country

* 31. Passport expiration date

* 32. Have you ever traveled outside of the United States to Indonesia or other countries? If yes, please explain the purpose of these visits and dates

* 33. I certify that my answers are true and complete to the best of my knowledge. If I am selected to join the Indonesia-U.S. Youth Leadership program, I agree to participate fully in all activities to the best of my ability, including a pre-program orientation, all program activities on George Mason University’s campus in the U.S. and in Indonesia, and post-program follow-on activities until October 2016. (If this the case, please type your name below)

* 34. Date

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