2015-08-21
326Study in the United States
Student Leader
Application Form
Personal Information:
| 1. | ||||||||||||||||||||||||||
| Family Name Kostichev | First Name Anton | Patronymic Georgievich | ||||||||||||||||||||||||
| (NOTE: AS IT APPEARS IN HIS/HER PASSPORT.) | ||||||||||||||||||||||||||
| 2. | 3. | 4. | ||||||||||||||||||||||||
| Date of Birth 08/12/1993 (MM/DD/YYYY) | City of Birth Tikhvin, Leningrad region | Country of Birth Russia | ||||||||||||||||||||||||
| 5. | 6. | |||||||||||||||||||||||||
| Country of Residence Russia | Country(ies) of Citizenship Russia | |||||||||||||||||||||||||
| 7. | ||||||||||||||||||||||||||
| Home Address Saint Petersburg, Vasileostrovsky District, 8 line, house 77 | ||||||||||||||||||||||||||
| City Saint Petersburg | Cell Phone 8 921 88 44 756 | E-mail antonkostichev@yandex.com | ||||||||||||||||||||||||
| (NOTE: Please include the telephone code for your city/region.) | ||||||||||||||||||||||||||
| 8. | ||||||||||||||||||||||||||
| Emergency Contact Name and Relationship (Example: John Doe, Father) Klimovich Anna (cousin) | Cell Phone 7 921 920 82 66 | E-mail vesna-love2006@mail.ru | ||||||||||||||||||||||||
| 9. | V Male | Female | ||||||||||||||||||||||||
| 10. | Medical, Physical, Dietary or other Personal Considerations (This will not affect candidate selection, but will enable the host institution to make any necessary accommodations): No | |||||||||||||||||||||||||
| Academic Major, Institution: | ||||||||||||||||||||||||||
| 11. | ||||||||||||||||||||||||||
| Major (специальность) | History | |||||||||||||||||||||||||
| 12. | ||||||||||||||||||||||||||
| Institution (название вуза и факультет) | Saint Petersburg State University, Faculty of History | |||||||||||||||||||||||||
| 13. | ||||||||||||||||||||||||||
| Year in School (курс) | ||||||||||||||||||||||||||
| 14. | Work and Volunteer Experience: | |||||||||||||||||||||||||
| Expeditions in the Vepsians forest | ||||||||||||||||||||||||||
| 2006 - ecological expedition on Lake Dolgozero | ||||||||||||||||||||||||||
| 2007 - ecological expedition on Lake Dolgozero 2008 - ecological expedition on River Ust-Kapsha 2009 - ecological expedition on Lake Dolgozero Other expeditions: 2010 - archaeological expedition in Ladoga (as member of a youth Camp “Gargarika”) (by Institute of Archaeology, Russian Academy of Sciences) 2012 - archaeological expedition in Nymphaion in Kerch (as trainee from St. Petersburg State University) (by The State Hermitage Museum) 2012 - voluntary assistance in organizing of International Conference 1812 in the fates of Russia and Europe | ||||||||||||||||||||||||||
| 15. | Memberships in Associations, Clubs, etc: | |||||||||||||||||||||||||
| Please include dates (Example: Student Government, May 2011 to June 2012) | ||||||||||||||||||||||||||
| Children's Environmental Center, September 2007 to May 2009 Debate club of the Faculty of Philosophy, September 2012 until now School of Music, 1998-2009 | ||||||||||||||||||||||||||
| 16. | U.S. Travel: | Yes V No | ||||||||||||||||||||||||
| Purpose | Date | |||||||||||||||||||||||||
| Yes No | ||||||||||||||||||||||||||
| 17. | Family Residing in the United States: Please list any immediate family members who are currently residing in the United States, including city and state: | Yes V No | ||||||||||||||||||||||||
| 18. | English Proficiency: | |||||||||||||||||||||||||
| Reading: | Excellent | V Good | Fair | |||||||||||||||||||||||
| Writing: | Excellent | V Good | Fair | |||||||||||||||||||||||
| Speaking: | Excellent | V Good | Fair | |||||||||||||||||||||||
19. Personal Statement:
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Tell us about yourself and your goals including the following: What about your background and/or interests 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, or approximately half a page, single spaced.
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Completed applications may be sent by e-mail: USGExchanges@gmail.com
