Open Society Scholarship Programs
2015 CIVIL SOCIETY LEADERSHIP AWARDS
Application Deadline: December 15, 2014
I.
Personal Information – Write your name exactly as it is written on your passport. Please write neatly and accurately.
Family Name: ________________________________ Given Name: _______________________________________
Gender:
_____________________________
Date of Birth (MM/DD/YYYY): ___________________ Place of Birth (city / country): __________________________________
Country of permanent legal residence: _________________ Country/-ies of citizenship:
________
Passport Number: ______________________________Country of Issue:_______________________________
Date of Expiration (MM/DD/YYYY):______________________
Have you ever applied for, or do you currently hold, a visa or permanent residency status for any of the participating university
countries? If so, describe and give expiration date of visa.
II.
Academic Program- Please refer to application guidelines when completing this question.
Field of Study:__________________________________________________________________
I would like to be considered for placement at the following participating universities:
1.________________________________________________________________________________
2._________________________________________________________________________________
3.__________________________________________________________________________________
Are you applying for any other scholarships this year (Open Society Foundations or other) or directly to an academic program?
Yes___ No ___
If yes, which ones? ____
_____
III. Current Employer- Include country and city code for phone numbers.
Current position/job title: ____________________________________________________________________________
Place of Employment: _____________________________________________________________________________
Number and Street: ______________________________________________________________________________
City/Region: ________________________________________________ Country: ___________________________
Work phone: (_____) __________________
Email: ____________________
IV. Mailing Address - All mail will be sent to this address during application review (until May 2015). Include country and city code
for phone number.
Number and Street: ______________________________________________________________________________
City/Region: ________________________________________________ Country: __________________________
Email: ________________________
Preferred Phone (_____)________________________________________
Skype username:__________________________________
V. Permanent Address– If different from mailing address.
Number and Street: _________________________________________________________________________
City/Region: ________________________________________________ Country: ______________
Preferred Phone (_____)___________________________
VI. Professional Experience – List your most recent professional experience first. Please include your full employment
history on your Curriculum Vitae and attach it to the application.
Name & Type of Organization
(include # of employees)
Job Title & Dates of Employment
(and # of people you supervised)
Job Responsibilities
(and hours worked per week)
Paid or
Volunteer
VII. Education – Starting with your most recent degree, please list the academic institutions you have attended, including
your secondary school.
Institution & Location
Major Field of Study
(area of specialization)
Degree / Diploma
(do not translate, write in
Latin letters)
Dates of Study
(starting & ending
month / year)
Date Degree
Received
(or expected)
VIII. Academic Awards - List any awards, grants, fellowships, or honors you have received.
Name of Award
Agency granting award
Year award granted
Location of primary
activity
Duration of
award/study
THIS FORM IS FREE AND MAY BE DUPLICATED
IX. Professional, Cultural or Civic Associations - List any professional or other associations to which you belong.
Name of organization
Your role in organization
Year joined association
Year association
founded
X. Conferences/Workshops/Trainings – List events you have attended that are relevant to your professional
interests and proposed field of study. If you gave a presentation, please write the topic in the last column.
Name of Event
Country
Dates
Participant or
Presenter?
Presentation Topic
XI. Testing - Please list any standardized test scores you have for graduate study (IELTS, TOEFL, GRE, etc.).
Name of Test
Testing Date
Testing Location
3
Score
THIS FORM IS FREE AND MAY BE DUPLICATED
XII. Language Ability - Rate your reading, writing, listening comprehension and speaking skills for each language you
know. Use the ratings of Excellent, Good, Fair, or Poor.
Language
Reading
Writing
Listening
Speaking
XIII. International Experience - Please indicate ALL extensive (more than one month) travel, study, or work you have
done outside your home country.
Country Visited
Length of Stay
Dates
Purpose of travel
XIV. Required Accommodations - Please identify any disability-related accommodations you require to enable you to
participate fully in an academic program. This information will have no bearing on the success of your application.
____ Physically accessible facilities
____ Flexible scheduling
____ Sign language interpretation
____ Communication Access Realtime Translation
Type:
(CART)
____ Materials in Braille
____ Personal Assistant (please describe in detail
____ Screen reading software
below)
____ Additional time for testing
____ Other. Please describe your needs:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
XV. Essays (Please answer all the questions below with a maximum of 250 words for each response):




Why have you chosen your specific field of study?
How would obtaining a graduate degree in this field help support civil society in your home country?
How has your personal experience and family background shaped your professional goals?
How do you define a civil society leader?
XVI. References - Please identify two (2) individuals, one academic and one professional, who will write recommendation
letters on your behalf. Please note that the selection committee weighs these letters heavily in evaluating applications.
1.
Name: _________________________________________ Title: ________________________________________
Mailing address: ______________________________________________________________________________
______________________________________________________________________________
Telephone number: ___________________________ E-mail:__________________________________________
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THIS FORM IS FREE AND MAY BE DUPLICATED
2.
Name: _________________________________________ Title: ________________________________________
Mailing address: ______________________________________________________________________________
______________________________________________________________________________
Telephone number: ___________________________ E-mail: _________________________________________
XVII. Required Order of Attachments - Please include the following items with your application in the order given
below:
1.
2.
3.
4.
Essay
Resume or Curriculum Vitae (CV), in English
Recommendation Letters (if not sent electronically)
Official university transcripts in original language
5.
6.
Certified English translation of transcripts
Photocopy of passport picture page (if available)
Program Administration (optional) - Please note that this information will not influence the outcome of your
application; it is strictly for internal program evaluation purposes.
Ethnicity:________________________________________________________________________
Father’s occupation:__________________________________________________________________________
Mother’s occupation:_________________________________________________________________________
Have you previously been admitted into a graduate degree program but did not enroll? Yes____No_____
If Yes, name and location of university:__________________________________________________
Reasons for not attending:______________________________________________________
How did you learn about the Program?



Advising Center
Soros/Open Society Office
Friend




Newspaper/Journal
Listserv ___ (name)
Website ________(name)
Television



Your university
Your workplace
Other ______
XVIII.
Certification and Disclosure - I certify that the information given in this application is complete and accurate. I
expressly authorize OSI, the Open Society Foundation in London, any other member of the Open Society Foundations,
any participating university, or any third party retained and authorized by such entities to act on their behalf only in the
context described herein to use, manage, collect, process, and store my personal data (including “sensitive data” or
“sensitive personal data” under applicable law) that I provide to OSI or any other member of the Open Society
Foundations in connection with this application, to further their charitable or educational purposes and in particular for
the purposes of processing this application and, if successful, arranging my receipt of a Civil Society Leadership Award
and my study at a participating university . As part of the process of dealing with my application and arranging my study,
my personal data will if necessary be transferred to countries outside of the European Economic Area where there may
be a lower standard of protection for personal data, and I consent to such transfer of my personal data.
Name:
Signature:
Date:
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THIS FORM IS FREE AND MAY BE DUPLICATED
SUBMIT BY DECEMBER 15, 2014
Late applications will automatically be disqualified. Paper applications submitted by mail must be postmarked by December
15, 2014 and sent to either the New York or London address listed below. Alternately, paper applications may also be sent to
one of the country administrative offices:
Open Society Foundations
Scholarship Programs
224 West 57th Street
New York, NY
10019, USA
Email: csla@infoscholar.org
Open Society Foundations
Scholarship Programs
Millbank Tower, 7th Floor
21-24 Millbank, London
SW1P 4QP, UK
Email: csla@infoscholar.org
Local administrative offices- contact address:
Azerbaijan
Baku Education Information Center
40 J. Jabbarli Street, Caspian Business Center
Baku AZ1065
Tel/Fax: (994 12) 4482845/46
Contact:
Bahar Haji-zada: bhaji-zada@beic.az
Turkmenistan + Uzbekistan
Educational Center: "Bilim–Central Asia"
25, Gani Ilyaev Str., Shymkent
160012, Kazakhstan
Tel./Fax (7252) 211981
Contacts:
Larissa Gurbunova: lgorbunova@bilim.kz
Arman Turdaliyev: aturdaliyev@gmail.com
Belarus
European Humanities University
Tauro g. 12m LT-10101 Vilnius
Lithuania Tel: 00370 5 274 0622
Contact:
Kevin Reiling: advising@ehu.lt
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Open Society Scholarship Programs
2015 Civil Society Leadership Award
Deadline: December 15, 2014
RECOMMENDATION FORM INSTRUCTIONS
Applicants for the Civil Society Leadership Awards are required to submit two recommendations from
professors or employers. Your candid, honest responses on the recommendation form provided below are
very important for our selection process and will ensure that successful candidates are placed in programs
that best fit their academic and professional goals.
Please take the time to provide detailed answers. You may continue answers on additional sheets of paper,
if more space is needed. We appreciate your taking the time to assist this applicant.
Recommenders should note the following guidelines:
 Recommendations must be signed and include the name, address, and telephone number of the
person providing the recommendation.
 Recommendations written in a language other than English must be accompanied by an English
translation. Applicants may not certify their own translations.
 Recommendations from individuals outside academia (employers, etc.) should write or mark
“unable to judge” for those questions that relate to purely academic issues.
 Recommendations may be completed electronically and submitted to csla@infoscholar.org
 If sending via email is not possible, recommendation letters should be returned to the applicant in
signed, sealed envelopes in time for the applicant to return them with his/her full application to our
offices by program deadline of December 15, 2014.
 Recommendations that are not returned to the applicant should be mailed to the appropriate office
at one of the addresses below.
Open Society Scholarship Programs
224 West 57th Street
New York, NY
10019, USA
Email: csla@infoscholar.org
Open Society Foundations
Scholarship Programs
Millbank Tower, 7th Floor
21-24 Millbank, London
SW1P 4QP, UK
Email: csla@infoscholar.org
Local administrative offices- contact address:
Azerbaijan
Baku Education Information Center
40 J. Jabbarli Street, Caspian Business Center
Baku AZ1065
Tel/Fax: (994 12) 4482845/46
Contact:
Bahar Haji-zada: bhaji-zada@beic.az
Belarus
European Humanities University
Tauro g. 12m LT-10101 Vilnius
Lithuania Tel: 00370 5 274 0622
Contact:
Kevin Reiling: advising@ehu.lt
Turkmenistan + Uzbekistan
Educational Center: "Bilim–Central Asia"
25, Gani Ilyaev Str., Shymkent
160012, Kazakhstan
Tel./Fax (7252) 211981
Contacts:
Larissa Gurbunova: lgorbunova@bilim.kz
Arman Turdaliyev: aturdaliyev@gmail.com
Open Society Scholarship Programs
2015 Civil Society Leadership Award
Deadline: December 15, 2014
Applicant’s Personal Information
Family Name
Given Name
Recommendation
To be completed by a lecturer, professor, employer, or supervisor who is familiar with the applicant.
Please complete the following form. Your candid, honest response will assist in selecting successful candidates and
placing them in programs that best meet their personal and academic requirements.
Your Name and Title (please print):
Academic Affiliation or Place of Employment:
Work Telephone & E-mail:
Signature:
Date:
In what capacity and for how long, have you known the applicant?
Please list the courses you have taught the applicant, if applicable.
Course
Year
Applicant's Grade
Please comment on the applicant's ability to contribute to the development of their field and civil society in your
country.
THIS FORM IS FREE AND MAY BE DUPLICATED
How do you think the applicant will benefit from a graduate program outside his / her home country?
Overall Evaluation
Compared to other people you have taught or employed, how would you rank the applicant in the following terms?
(Circle the best answer.)
Leadership
Motivation
Creative/Independent thinking
Effective communication skills
English language skills
Respect for others
Academic success
no basis
no basis
no basis
no basis
no basis
no basis
no basis
poor
poor
poor
poor
poor
poor
poor
Overall, how would you rate this applicant?
no basis
poor
average
very good
average
average
average
average
average
average
average
excellent
very good
very good
very good
very good
very good
very good
very good
excellent
excellent
excellent
excellent
excellent
excellent
excellent
One of the top
students/employees
I have encountered
If you have completed recommendation forms for other applicants for the Civil Society Leadership Awards,
how does this applicant compare to them?
no basis
poor
average
very good
excellent
One of the top
students/employees
I have encountered
Please use this space for any additional comments you would like to make about the applicant and add additional
pages, if desired.