<p> 2016 U.S. Department of State and espnW Global Sports Mentoring Program</p><p>Application Checklist</p><p>Name</p><p>Age </p><p>Gender</p><p>City</p><p>Previous travel to the U.S.? If yes, please specify duration and type of visit Moroccan Citizen  Yes  No Number of Years of Work Experience </p><p>Current Employer</p><p>Level of Education (bachelors, masters, PhD, other)</p><p>In order for your application to be complete, please make sure you have:</p><p> Completed application checklist form (this page)</p><p> Completed application form (pages 2- 6 of this document)</p><p> Copy of passport</p><p> Most recent curriculum vitae</p><p> One or two recommendation letter(s)</p><p>* Completed applications and required attachments must be received via e-mail by June 8, 2016. Any applications received after this time will not be considered. Please e-mail all applications and supporting documents to: [email protected] </p><p>Page 1 of 6 U.S. Department of State and espnW Global Sports Mentoring Program</p><p>Application Form 2016</p><p> Name: ______(First name) (Last name)</p><p> City and Country of Birth: </p><p> Date of Birth written in full: (Month) (Day) (Year)</p><p> Passport no: </p><p>Date of issuance: ______(Month) (Day) (Year)</p><p>Date of expiration: ______(Month) (Day) (Year)</p><p> Marital Status:</p><p> Citizenship: </p><p> Special considerations, such as allergies, medical and physical challenges, dietary preferences:</p><p> Business address, telephone and fax numbers:</p><p> E-mail address:</p><p> Home address and telephone: </p><p> Preferred Mailing Address: Business ( ) Home ( )</p><p> Languages:</p><p> o Native Language: </p><p> o English Proficiency: . Speaking: . Comprehension: . Written:  Social Media: If available, please provide information on any social media tools that you may use. These include Twitter, Facebook personal account, Facebook organization account, or Page 2 of 6 other.</p><p> Present Position: (exact title, starting date, and brief description of role in company/organization) </p><p> Full Name of Company/Organization:</p><p> Brief Description of Company/Institution: (Please Include information on the organization's sector (private, public, non-governmental), number of employees, annual budget, organization mission, relevance to the sports sphere, and website)</p><p> Professional memberships in local, national or international professional organizations or associations or clubs: </p><p> Previous travel to the United States: (Please note if applicant has ever traveled on a U.S. government program) </p><p> o Dates: o Places Visited: o Sponsorship/Purpose of Visit:</p><p> Other Travel Abroad</p><p> o Dates: o City and Country: o Principal Purpose of Visit: </p><p> o Dates: o City and Country: o Principal Purpose of Visit: </p><p> o Dates: o City and Country: o Principal Purpose of Visit:</p><p> Educational Background: (List highest degree first. Include significant training programs) Page 3 of 6 o Dates: o Degree/Certificate: o Institutions: o Field of Specialization: </p><p> Other Interests and endeavors outside of work: (Hobbies, Volunteer Activities, etc.)</p><p>Page 4 of 6 PERSONAL STATEMENT</p><p>Please answer all of the following questions in your personal statement: This can be more than one page, but it is important that all six questions are answered in the following order.</p><p>1- Why do you think you will be a good fit for this exchange program? 2- What do you hope to gain from the mentorship experience and how will you maximize the opportunity? 3- What are your personal, executive, and technical strengths? 4- What are your accomplishments and contributions to society, particularly in the context of sports and female empowerment? 5- What are your personal interests outside business? 6- How do you expect the program to impact your work when you return to Egypt?</p><p>Page 5 of 6 RECOMMENDATION CONTACT</p><p>Identify one individual (or more) who can provide you a letter of recommendation (other than the one to be submitted with the application). Please have this/these recommendation(s) letter ready with you if you are called back for an interview.</p><p>Name Title Mailing Address Telephone Number Email Address</p><p>Name Title Mailing Address Telephone Number Email Address</p><p>Page 6 of 6</p>