PRELIMINARY APPLICATION FORMKennedy Lugar Youth Exchange & Study (KL-YES)

Academic Year 2021-2022Country: Bangladesh

Please read all the instructions and check the requirements carefully before filling out this application. Use black ink. Your application must be filled completely and honestly. Submit this application with necessary documents to iEARN-BD office

by 5PM of November 15, 2020.

Student’s Information (Mandatory)

Required Documents (Mandatory)Passport Size Photo Attested Birth Certificate Attested Transcripts of current year, 2019 & 2018

Last Name:

Do you hold or have held any nationality other than the one mentioned above?

Date of Birth: Citizenship:

Yes No

Do you have any disabilty/disabilities? Yes No

FemaleMaleSex:

Email ID:

Contact Number:

Given Name:Last part of your name as it appears or will appear on the passport.

As on your birth certificate.

Please provide your personal email address as it is mandatory for applying to this program.

Rest of your name excluding the last part of the name as it appears or will appear on the passport.

You must be a Bangladeshi citizen to apply for this program

Other

Please provide a valid phone number which will be used to send all necessary information/updates to the applicant. It is not necessary that the applicant must have a personal number, but we must be able to reach the applicant at the number provided at all times.

You must be a Bangladeshi citizen only to be eligible for this application.

Your disability will not impact your chances.

If yes, which country?

Do you have a passport? If yes please enter your passport number:

If yes, enter your Facebook URL:

If yes, explain.

Yes No

Do you have Facebook? Yes No

If yes, enter your Instagram ID:

Do you have Instagram? Yes No

If yes, enter your Twitter handle:

Do you have Twitter? Yes No

Enter your passport date of expiry:

PRELIMINARY APPLICATION FORM

mm/dd/yy

Enter your postal address. We will send you physical letters to this address.

Enter your thana/police station here.

Enter your district here.

Enter your place of birth according to your Birth Certificate/passport.

Enter your postcode here. To find your postcode, visit: www.bangladeshpost.gov.bd/find-post-code.html

Present Address:

Postal Code:

Thana:

District:

Place of Birth:

Mailing/Postal Address (Mandatory)

Academic Year 2020

Academic Background (Mandatory)

School’s Information (Mandatory)

Parents’ Information (Mandatory)

The grade you are studying in. The average percentage marks that you got in your current grade so far. If unavailable, leave blank.

Current Grade/Class you are in: Percentage Marks in Current Grade:

Academic Year 2019

The grade you studied in 2019. The average percentage marks that you got in 2019.

Previous Grade/Class you were in: Percentage Marks in 2019:

Academic Year 2018

The grade you studied in 2018. The average percentage marks that you got in 201 8.

Grade/Class you studied in 2018: Percentage Marks in 2018:

PRELIMINARY APPLICATION FORM

Address:

School Name:

Postal Code:School Contact Number:

Principal/Headmaster/Headmistress Name:

Principal/Headmaster/Headmistress Contact Number:

Father’s Full Name:

Contact Number:

Email ID:

Occupation

Father NID:

Monthly Income (approximate):

Thana:

District:

Address of your current educational institution.

Official phone number for your educational institution.

Name of the Principal/Headmaster/Headmistress of your current educational institution.

The contact number of the Principal/Headmaster/Headmistress of your current educational institution.

Name of the educational institution you are currently studying in.

Postal code of your current educational institution.

Thana/police station of your current educational institution.

District of your current educational institution.

Full name of your father.

Cell phone number of your father.

Email address of your father.

Occupation of your father.

National/Voter ID Card Number of your father.

Approximate monthly income of your father.

If you have marked yes, provide which of your family members have participated/completed the KL-YES Program and in which academic year.

Mother’s Full Name:

Contact Number:

Email ID:

Occupation

Mother NID:

Monthly Income (approximate):

Full name of your mother.

Cell phone number of your mother.

Email address of your mother.

Occupation of your mother.

National/Voter ID Card Number of your mother.

Approximate monthly income of your mother.

Is your father alive and known to you? Yes No Is your mother alive and known to you? Yes No

Travel and Family Immigration Information (Mandatory)Has anyone in your family participated in the KL-YES Program in the past? Yes NoIf yes, who and when?:

List when and which state(s) you have visited.

Explain why you visited the U.S. The number of days you were in the U.S. in the last 5 years.

Have you visited the United States in the last 5 years? Yes No

Purpose of your visit?: How long did you stay? (in days):

If yes, when and where?:

PRELIMINARY APPLICATION FORM

Travel and Family Immigration Information (Mandatory)

Bio (Mandatory)

Has anyone ever filed an immigrant petition on your behalf with the U.S. Citizen and Immigration Services?

Please write a small paragraph about yourself within 100 words. There must be a minimum of 5 sentences in the paragraph. Please write the paragraph in clear handwriting or font and within the space provided:

Yes NoIs anyone in your immediate family (Father/Mother/Siblings) a U.S. Green Card holder? Yes NoIs anyone in your immediate family (Father/Mother/Siblings) currently living in the U.S.? Yes NoIs any of your relatives currently living in the U.S.? Yes No Do you hold a valid U.S. visa? Yes No

If yes, which state?: If yes, when does the visa expire?: mm/dd/yy

List which countries you visited in the last 5 years and why.

Have you visited any other country in the last 5 years? Yes No

If yes, list which countries and purposes:

PRELIMINARY APPLICATION FORM

Applicant’s signature

Mother’s signature

Father’s signature

Date:

Date:

Date:

I hereby declare that, as the primary and sole applicant for this application, the information I have provided is absolutely true and correct. I also understand that any willful dishonesty, that may get discovered later, will render this application void, and result in immediate disqualification of my candidacy from the K-L YES Program of the 2021-2022 academic year.

How did you get to know about the KL-YES Program?

Other

YES Program Website

Flyers/PostersInstagram

My High School/TeacherTwitter

A Friend

A YES Alumni MemberiEARN-BD Website

Newspaper

iEARN-BD Staff Member

My Family Member

Facebook

If other, explain how you got to know about the program:

Have you ever visited a psychologist or a psychiatrist? Yes NoThis will not impact your chances.

U.S. Embassy Website/The American Center Dhaka/EMK Center