Open Society Scholarship Programs

Open Society Scholarship Programs 2015 CIVIL SOCIETY LEADERSHIP AWARDS Application Deadline: December 15, 2014

I. Personal Information – Write your name exactly as it is written on your passport. Please write neatly and accurately.

Family Name: ______Given Name: ______Gender: ______Date of Birth (MM/DD/YYYY): ______Place of Birth (city / country): ______Country of permanent legal residence: ______Country/-ies of citizenship: ______Passport Number: ______Country of Issue:______Date of Expiration (MM/DD/YYYY):______

Have you ever applied for, or do you currently hold, a visa or permanent residency status for any of the participating university countries? If so, describe and give expiration date of visa.

II. Academic Program- Please refer to application guidelines when completing this question. Field of Study:______

I would like to be considered for placement at the following participating universities: 1.______

2.______

3.______

Are you applying for any other scholarships this year (Open Society Foundations or other) or directly to an academic program? Yes___ No ___

If yes, which ones? ______

III. Current Employer- Include country and city code for phone numbers.

Current position/job title: ______

Place of Employment: ______

Number and Street: ______

City/Region: ______Country: ______

Work phone: (_____) ______Email: ______

IV. Mailing Address - All mail will be sent to this address during application review (until May 2015). Include country and city code for phone number.

Number and Street: ______

City/Region: ______Country: ______

Email: ______Preferred Phone (_____)______

Skype username:______VI. V. VIII. VII. employment history on your Curriculum Vitae andattachittotheapplication. historyonyour CurriculumVitae employment ProfessionalExperience – Phone(_____)______Preferred Country:______City/Region: andStreet:______Number Address–Permanent school. your secondary – Education Academic Academic Awards - Name & Type of Name OrganizationType of & Institution & InstitutionLocation (include # of (include employees)of # Name of Awardof Name Starting with your most recent degree, please list the academic institutions you have attended, including attended,including academic institutionsyou have degree,pleaselistthe Starting with your most recent L If different from mailingaddress. If different ist any awards, grants, fellowships, or honors you havereceived. grants,fellowships, orhonors ist any awards, Agency Agency granting award (area of specialization)(area of List your most recent professional experience first. Please includeyour full experiencefirst.Please List your most recentprofessional Major Field of StudyMajorof Field (and # of people you supervised) people(andof you# Job DatesEmploymentTitleof & (do not translate, write in not(do translate, Year award granted Degree / DegreeDiploma / Latin letters)Latin (and hours worked week)per(and hours Job Responsibilities Location of primaryofLocation (starting & ending(starting Dates of Studyof Dates month / year)month activity (or (or expected) Date DegreeDate award/study Duration ofDuration Received Volunteer Paid or

THIS FORM IS FREE AND MAY BE DUPLICATED

IX. Professional, Cultural or Civic Associations - List any professional or other associations to which you belong. Name of organization Your role in organization Year joined association Year association founded

X. Conferences/Workshops/Trainings – List events you have attended that are relevant to your professional interests and proposed field of study. If you gave a presentation, please write the topic in the last column. Name of Event Country Dates Participant or Presentation Topic Presenter?

XI. Testing - Please list any standardized test scores you have for graduate study (IELTS, TOEFL, GRE, etc.). Name of Test Testing Date Testing Location Score

3 THIS FORM IS FREE AND MAY BE DUPLICATED XII. Language Ability - Rate your reading, writing, listening comprehension and speaking skills for each language you know. Use the ratings of Excellent, Good, Fair, or Poor. Language Reading Writing Listening Speaking

XIII. International Experience - Please indicate ALL extensive (more than one month) travel, study, or work you have done outside your home country. Country Visited Length of Stay Dates Purpose of travel

XIV. Required Accommodations - Please identify any disability-related accommodations you require to enable you to participate fully in an academic program. This information will have no bearing on the success of your application.

____ Physically accessible facilities ____ Flexible scheduling ____ Sign language interpretation ____ Communication Access Realtime Translation Type: (CART) ____ Materials in Braille ____ Personal Assistant (please describe in detail ____ Screen reading software below) ____ Additional time for testing ____ Other. Please describe your needs: ______

XV. Essays (Please answer all the questions below with a maximum of 250 words for each response):

Why have you chosen your specific field of study? How would obtaining a graduate degree in this field help support civil society in your home country?  How has your personal experience and family background shaped your professional goals? How do you define a civil society leader?

XVI.References - Please identify two (2) individuals, one academic and one professional, who will write recommendation letters on your behalf. Please note that the selection committee weighs these letters heavily in evaluating applications.

1. Name: ______Title: ______Mailing address: ______Telephone number: ______E- mail:______

4 THIS FORM IS FREE AND MAY BE DUPLICATED

2. Name: ______Title: ______Mailing address: ______Telephone number: ______E-mail: ______

XVII. Required Order of Attachments - Please include the following items with your application in the order given below: 1. Essay 5. Certified English translation of transcripts 2. Resume or Curriculum Vitae (CV), in English 6. Photocopy of passport picture page (if available) 3. Recommendation Letters (if not sent electronically) 4. Official university transcripts in original language

Program Administration (optional) - Please note that this information will not influence the outcome of your application; it is strictly for internal program evaluation purposes.

Ethnicity:______Father’s occupation:______Mother’s occupation:______

Have you previously been admitted into a graduate degree program but did not enroll? Yes____No_____

If Yes, name and location of university:______

Reasons for not attending:______

How did you learn about the Program?  Advising Center  Newspaper/Journal  Your university  Soros/Open Society Office  Listserv ___ (name)  Your workplace  Friend  Website ______(name)  Other ______ Television

Certification and Disclosure - I certify that the information given in this application is complete and accurate. I expressly authorize OSI, the Open Society Foundation in London, any other member of the Open Society Foundations, any participating university, or any third party retained and authorized by such entities to act on their behalf only in the context described herein to use, manage, collect, process, and store my personal data (including “sensitive data” or “sensitive personal data” under applicable law) that I provide to OSI or any other member of the Open Society Foundations in connection with this application, to further their charitable or educational purposes and in particular for the purposes of processing this application and, if successful, arranging my receipt of a Civil Society Leadership Award and my study at a participating university . As part of the process of dealing with my application and arranging my study, my personal data will if necessary be transferred to countries outside of the European Economic Area where there may be a lower standard of protection for personal data, and I consent to such transfer of my personal data.

Name: Signature:

5 THIS FORM IS FREE AND MAY BE DUPLICATED Date:

SUBMIT BY DECEMBER 15, 2014

Late applications will automatically be disqualified. Paper applications submitted by mail must be postmarked by December 15, 2014 and sent to either the New York or London address listed below. Alternately, paper applications may also be sent to one of the country administrative offices:

Open Society Foundations Open Society Foundations Scholarship Programs Scholarship Programs 224 West 57th Street Millbank Tower, 7th Floor New York, NY 21-24 Millbank, London 10019, USA SW1P 4QP, UK Email: [email protected] Email: [email protected]

Local administrative offices- contact address:

Azerbaijan Turkmenistan + Uzbekistan Baku Education Information Center Educational Center: "Bilim–Central Asia" 40 J. Jabbarli Street, Caspian Business Center 25, Gani Ilyaev Str., Shymkent Baku AZ1065 160012, Kazakhstan Tel/Fax: (994 12) 4482845/46 Tel./Fax (7252) 211981 Contact: Contacts: Bahar Haji-zada: [email protected] Larissa Gurbunova: [email protected] Arman Turdaliyev: [email protected] Belarus European Humanities University Tauro g. 12m LT-10101 Vilnius Lithuania Tel: 00370 5 274 0622 Contact: Kevin Reiling: [email protected]

6 Open Society Scholarship Programs 2015 Civil Society Leadership Award

Deadline: December 15, 2014

RECOMMENDATION FORM INSTRUCTIONS

Applicants for the Civil Society Leadership Awards are required to submit two recommendations from professors or employers. Your candid, honest responses on the recommendation form provided below are very important for our selection process and will ensure that successful candidates are placed in programs that best fit their academic and professional goals.

Please take the time to provide detailed answers. You may continue answers on additional sheets of paper, if more space is needed. We appreciate your taking the time to assist this applicant.

Recommenders should note the following guidelines:  Recommendations must be signed and include the name, address, and telephone number of the person providing the recommendation.  Recommendations written in a language other than English must be accompanied by an English translation. Applicants may not certify their own translations.  Recommendations from individuals outside academia (employers, etc.) should write or mark “unable to judge” for those questions that relate to purely academic issues.  Recommendations may be completed electronically and submitted to [email protected]  If sending via email is not possible, recommendation letters should be returned to the applicant in signed, sealed envelopes in time for the applicant to return them with his/her full application to our offices by program deadline of December 15, 2014.  Recommendations that are not returned to the applicant should be mailed to the appropriate office at one of the addresses below.

Open Society Scholarship Programs Open Society Foundations 224 West 57th Street Scholarship Programs New York, NY Millbank Tower, 7th Floor 10019, USA 21-24 Millbank, London Email: [email protected] SW1P 4QP, UK Email: [email protected] Local administrative offices- contact address: Lithuania Tel: 00370 5 274 0622 Contact: Azerbaijan Kevin Reiling: [email protected] Baku Education Information Center 40 J. Jabbarli Street, Caspian Business Center Baku AZ1065 Turkmenistan + Uzbekistan Tel/Fax: (994 12) 4482845/46 Educational Center: "Bilim–Central Asia" Contact: 25, Gani Ilyaev Str., Shymkent Bahar Haji-zada: [email protected] 160012, Kazakhstan Tel./Fax (7252) 211981 Belarus Contacts: European Humanities University Larissa Gurbunova: [email protected] Tauro g. 12m LT-10101 Vilnius Arman Turdaliyev: [email protected] Open Society Scholarship Programs 2015 Civil Society Leadership Award

Deadline: December 15, 2014

Applicant’s Personal Information

Family Name Given Name

Recommendation To be completed by a lecturer, professor, employer, or supervisor who is familiar with the applicant.

Please complete the following form. Your candid, honest response will assist in selecting successful candidates and placing them in programs that best meet their personal and academic requirements.

Your Name and Title (please print):

Academic Affiliation or Place of Employment:

Work Telephone & E-mail:

Signature: Date:

In what capacity and for how long, have you known the applicant?

Please list the courses you have taught the applicant, if applicable.

Course Year Applicant's Grade

Please comment on the applicant's ability to contribute to the development of their field and civil society in your country.

How do you think the applicant will benefit from a graduate program outside his / her home country?

Overall Evaluation Compared to other people you have taught or employed, how would you rank the applicant in the following terms? (Circle the best answer.)

Leadership no basis poor average very good excellent Motivation no basis poor average very good excellent Creative/Independent thinking no basis poor average very good excellent Effective communication skills no basis poor average very good excellent English language skills no basis poor average very good excellent Respect for others no basis poor average very good excellent Academic success no basis poor average very good excellent

Overall, how would you rate this applicant? no basis poor average very good excellent One of the top students/employees I have encountered

If you have completed recommendation forms for other applicants for the Civil Society Leadership Awards, how does this applicant compare to them? no basis poor average very good excellent One of the top students/employees I have encountered

Please use this space for any additional comments you would like to make about the applicant and add additional pages, if desired.