PERSONAL INFORMATION

Name (First, Middle initial, Last)

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

Net ID

Email Address

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)

Letter of Recommendation from:

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

What languages do you speak?

Years of study (for each language)

If you have been accepted into a study abroad program for the fall (2011) or spring (2011), please
indicate the semester and location where you will be.

Have you previously applied for a Kellogg internship?
--- Y N

If yes, when and to what location(s)?

Top three site requests:
First Choice: --- DOMESTIC The Advocates for Human Rights - Minnesota Center of Concern - Washington DC Inter American Press Association – Miami Organization of American States – Washington, DC INTERNATIONAL Center for Microfinance – Brazil Child Family Health International - India Compassion for Migrant Children - China Coprodeli - Peru Ford Program - Uganda Foreign Commercial Service - Argentina Foundation for International Medical Relief of Children - Uganda Foundation for Sustainable Development – Argentina Foundation for Sustainable Development – Bolivia Foundation for Sustainable Development – India Foundation for Sustainable Development – Nicaragua Foundation for Sustainable Development – Uganda Hutong School - China Parceiros da Educação - Brazil Un Techo para mi Pais - Chile United Planet – Ghana Women in Progress – Ghana WorldTeach - China WorldTeach - Costa Rica WorldTeach - Ecuador WorldTeach - Namibia WorldTeach - South Africa Other
Second Choice: --- DOMESTIC The Advocates for Human Rights - Minnesota Center of Concern - Washington DC Inter American Press Association – Miami Organization of American States – Washington, DC INTERNATIONAL Center for Microfinance – Brazil Child Family Health International - India Compassion for Migrant Children - China Coprodeli - Peru Ford Program - Uganda Foreign Commercial Service - Argentina Foundation for International Medical Relief of Children - Uganda Foundation for Sustainable Development – Argentina Foundation for Sustainable Development – Bolivia Foundation for Sustainable Development – India Foundation for Sustainable Development – Nicaragua Foundation for Sustainable Development – Uganda Hutong School - China Parceiros da Educação - Brazil Un Techo para mi Pais - Chile United Planet – Ghana Women in Progress – Ghana WorldTeach - China WorldTeach - Costa Rica WorldTeach - Ecuador WorldTeach - Namibia WorldTeach - South Africa Other
Third Choice: --- DOMESTIC The Advocates for Human Rights - Minnesota Center of Concern - Washington DC Inter American Press Association – Miami Organization of American States – Washington, DC INTERNATIONAL Center for Microfinance – Brazil Child Family Health International - India Compassion for Migrant Children - China Coprodeli - Peru Ford Program - Uganda Foreign Commercial Service - Argentina Foundation for International Medical Relief of Children - Uganda Foundation for Sustainable Development – Argentina Foundation for Sustainable Development – Bolivia Foundation for Sustainable Development – India Foundation for Sustainable Development – Nicaragua Foundation for Sustainable Development – Uganda Hutong School - China Parceiros da Educação - Brazil Un Techo para mi Pais - Chile United Planet – Ghana Women in Progress – Ghana WorldTeach - China WorldTeach - Costa Rica WorldTeach - Ecuador WorldTeach - Namibia WorldTeach - South Africa Other

Please give specific details regarding your above site requests (i.e. FSD, India, gender studies, human
rights; Ghana, United Planet, environment, etc.)

Students must be flexible with regards to dates of participation which are established
by sites.
List any dates between May 19 and August 18, 2012 when you are NOT available to participate in an internship.

How did you learn about this Kellogg Institute internship opportunity?

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

Although every effort is made to place you in your internship of choice, you are not guaranteed placement
in the top three choices that you indicated above.

SIGNATURE

DATE