Benjamin Franklin Transatlantic Fellows Summer Institute Registration Form

1.  Last (family) name as on passport:

2.  First name as on passport:

3.  Middle name(s) as on passport:

4.  Date of birth (month/day/year):

5.  City of birth:

6.  Country of birth:

7.  Country of citizenship:

8.  Do you have an international passport?     Yes          No

9.  Full address (zip code, city, street, etc.):

10.  Phone number:

11.  E-mail address(es):

12.  Skype name:

13.  Name of high school:

14.  Grade/year at school:

15.  Field of study (if applicable):

16.  Any other relevant educational, academic and professional experience or training:

17.  Active memberships, special interests, or extracurricular activities:

18.  Future study or career plans:

19.  Previous travel or study experience in the United States (Please include dates and purpose):

20.  Medical, physical, dietary, or other personal considerations (e.g. allergies):