SUSI 2017 - Candidate Application Form
Deadline: Sunday. September 18, 2016 / 5:00 PM
Form must be completed in English.
  • Full Name, as shown on personal Passport or cédula.
  • Scan your ID (cédula) and upload it here using any of these formats: PDF, PNG or JPG. File size limit: 2MB.
  • Date (mm/dd/yyyy) / Place
  • Primary / Secondary (if applicable)
  • The place where you actually live
  • Please describe any pre-existing medical conditions, including any prescription medication you may be taking, allergies, or other dietary or personal consideration.

    This will not affect candidate selection, but will enable the host institution to make any necessary accommodations.
  • Numbers Only. For example: 25555555
  • Numbers Only. For example: 099555555
  • Name / Relationship / Phone / Email
    Example: John Doe / Father / 59824002233 / johndoe@email.com
  • Please include:

    Main Field of study and career

    Name and complete address of University or academic institute:
    Name, address and years of high school.
    Name, address and years of elementary school.

    Please explain any gaps in your education / Have you ever been dismissed from a school or university? If yes, explain why.
  • Please indicate:
    Currently studying …… year of career
    Expected graduation date: …………
    Do you have a scolarship? If yes, please specify.
  • Please indicate any scholarships, academic awards or honors that you have received and the year received.
  • Upload a scanned copy of a recommendation letter from your University using any of these formats: PDF, RTF, PNG, DOC, DOCX, JPG, GIF, JPEG. The letter must be signed. File size limit: 2MB.
  • Upload a scanned copy of Official Transcripts of Years of University Study using any of these formats: PDF, RTF, PNG, DOC, DOCX, JPG, GIF, JPEG. File size limit: 2MB.

    Fotocopia de la Escolaridad. No es necesario traducir.
  • Active extra-academic or voluntary activities, independent of current professional responsibilities.

    These should not include university committee work or other professional duties directly related to current employment

    Please include: Position / Title / Organization
  • Upload a scanned copy of a recommendation letter from your Volunteer Institution using any of these formats: PDF, RTF, PNG, DOC, DOCX, JPG, GIF, JPEG. The letter must be signed. File size limit: 2MB.
  • Are you an active member of any Association, Club or Group? Tell us about it!.
  • Please list all your previous trips to the United States and other countries and include approximate dates and the reason for travel.

    From ……......….. to ….......….… Purpose………………………
    Scholarhip= YES - NO (If yes, please specify)
  • Please list any immediate family members who are currently residing in the United States, including city and state.
  • If you have them, please attach a scanned copy of your English diplomas or certificates using any of these formats: PDF, RTF, PNG, DOC, DOCX, JPG, GIF, JPEG. File size limit: 2MB.
  • In a couple of sentences
  • In a couple of sentences
  • In a couple of sentences
  • Please list any immediate family members who are currently residing in the United States, including city and state.
  • Tell us about yourself and your goals. Please answer all the following questions:

    What about your background and/or interests that makes you competitive for this particular institute (please be as specific as possible)?

    What will you contribute to the group?

    How do you expect this experience will affect your future academic and professional career?

    How will it affect you personally?

    Please structure your essay in paragraphs and limit your response to 250 words, single spaced.
  • Please discuss why you wish to participate in this program. Include how your participation in the Institute will enhance your work, improve education about the United States in your community, and help you achieve the "Other potential Outcomes" you have checked above.

    IMPORTANT: Make sure your Video is available to the public or provide required access credentials (login info). If we cannot see the video, your application will be incomplete.