PERSONAL INFORMATION

Name (First, Last)

Student ID (e.g. 900123456, NOT your Social Security #)

Net ID (e.g. jsmith)

Email

Local Address

City

State
--- AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip

Local Phone

Permanent Address

City

State
--- AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip

Permanent Phone

Parent(s) Name(s)

PERSONAL INFORMATION

Date of Birth (e.g. 06/11/1990)

Gender
--- M F

First Race/Ethnicity
--- African American or Black Asian or Pacific Islander Native American or Alaska native or American Indian White Caucasian or non-Hispanic/Latino White Hispanic or Latino Non white Hispanic or Latino Other race or ethnicity, please specify Multiracial or multiethnic Prefer not to answer

Second Race/Ethnicity
--- African American or Black Asian or Pacific Islander Native American or Alaska native or American Indian White Caucasian or non-Hispanic/Latino White Hispanic or Latino Non white Hispanic or Latino Other race or ethnicity, please specify Multiracial or multiethnic Prefer not to answer

Other Ethnicity

In what country do you hold a citizen passport?

If not a U.S. citizen, what is your Visa status?

ACADEMIC INFORMATION

Expected Graduation Year

Overall GPA

Major(s)

Minor(s)

Do you have any past or current physical or health challenges that may limit international travel/activities? Please explain past and/or present history.

PROJECT INFORMATION

Title of Project

Proposed Country of Project

Dates of Project

What Notre Dame course(s) have you taken that relate to you proposed project?

Languages Spoken

Years of study (for each language)

To which countries have you traveled in the past?

Letter of Recommendation (Name of recommender # 1)

Letter of Recommendation (Name of recommender # 2)

How did you learn about this award?

If you have been accepted into a study abroad program for the fall (2012), please indicate the location where you will be.

BUDGET

Funds Requested

Travel

Food/Lodging

Other

Total

FUNDING SUPPORT

List all other grants you have applied for to fund this project.

This application and all supporting documents must be received at the Kellogg Institute no later than 5pm on the day of the deadline.

NOTE - Students who are accepted for this award are required to attend an orientation on Wednesday, April 4 from 6:30 – 8:30pm at the Hesburgh Center for International Studies. Additional mandatory orientation dates will be provided at a later time. Alternative orientations will be provided for students who are currently abroad.

SIGNATURE

DATE