2015

THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION

INSTRUCTIONS
Note to applicant: Complete this
form on your computer, save it and
email the completed form to the
address below. Specific instructions
for each form are located at the top of
the form. Email, fax or mail the
completed application to the address
below.
Forms 5 & 6 should be downloaded
separately and emailed to your
referees to be filled out and sent
directly to the Hansen Summer
Institute. Attach an official transcript of
your last two full years of university
study.
APPROXIMATE PROGRAM DATES:
June 29 July 20, 2015
DUE DATE: RETURN THE COMPLETED
APPLICATION POSTMARKED BY
JANUARY 5, 2015. If you do not return the
completed application by the postmark date,
your application will not be considered.
Email, Fax or Mail your application.
EMAIL application to blamb@sandiego.edu,
FAX application to 619-849-8195
OR MAIL your application to
The Hansen Summer Institute on Leadership
and International Cooperation University of
San Diego
School of Leadership and Education Sciences
5998 Alcala Park
San Diego, California 92110-2492

ELIGIBILITY REQUIREMENTS:

Be under 25 years of age with at least two

(2) years of college/university or a
graduate student in good standing.

Demonstrated commitment to community,

national or international service

Preference will be given to those who

have not visited the the United States
before this 2015 program

An academic advisor must verify, in

writing, your English proficiency. Semifinalists will be required to participate in a
telephone interview.

All materials, essays and other

documentation must be original.
Any quoted sources must be
properly credited.

FORM 1. BIOGRAPHICAL INFORMATION

APPLICANT INFORMATION (write your name as it appears or will appear in your
passport)
Sabina Ester
Lengkong
Melly
Family Name ____________
First Name____________
Middle Name_______
Male

Female

Bekasi
______________
Place of Birth

08/25/1995
Date of Birth: _____________
Indonesia
________________
Country of Birth

The Republic of Indonesia

_____________________
Country of Citizenship

Jl. Kusuma Timur C A6 No.10

Bekasi Timur
_____________________________________________
__________________
Permanent Address
City
West Java
Indonesia
17111
_________________________
________________________
________
Province or State
Country
Postal Code
62218804967
_______________________
Home Telephone Number

6281310640549
____________________
Work or Mobile Phone Number

Have you ever been to the United States before?

Yes

No

If yes, for how long? Dates From: _____________ To: _______________

_______________________________________________
Purpose of Visit to the United States
Airport closest to you: ________________________
CURRENT CONTACT INFORMATION
Jl. Kusuma Timur C A6 No.10
Bekasi Timur
17111
___________________________
_____________________
______________
Address
City
Postal Code
West Java
Indonesia
______________________
__________________________
Province or State
Country
62218804967
6281310640549
_____________________
_____________________________
Home Telephone Number
Work or Mobile Telephone Number
emellysabina@yahoo.com
___________________________________
Email Address
6281310640549
_______________________________________
Best telephone number where you can be reached for purposes of an interview
EMERGENCY CONTACT INFORMATION
____________________________
____________________
Name
Relationship to You
_______________________________________
Address
_____________________
________________
___________
Country
Postal Code
City
___________________________
_______________________
Work or Mobile Telephone Number
Home Telephone Number
UNIVERSITY OR COLLEGE INFORMATION
Christian University of Indonesia
______________________________________
Name of Institution
Jl. Mayjend Sutoyo No.2, Cawang
_________________________________________
Address
East Jakarta
Indonesia
13630
____________________
________________
_______________
City
Country
Postal Code
International Relations
_________________________________
Your Faculty or Major

2015

THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION

Melly Sabina Ester Lengkong

Applicant Name _____________________________________

FORM 2. ACTIVITIES AND ACHIEVEMENTS

SECTION 1
List your activities and interests and
indicate how many hours each
month you spent on each activity,
during the last three years only. You
can include:

Clubs and organizations

you have joined.

Sports played.
Other activities such as
religious or youth groups,
volunteering, social
activities.

Special training or hobbies.

Work experience.

SECTION 2
List any awards or prizes you
have received, and any
significant achievements for
which you have been
recognized.
Examples include prizes,
honors, medals or leadership
positions
SECTION 3
If you have traveled to or lived in
any other countries list in this
section:

ACTIVITIES, INTERESTS AND SPORTS

My activities are study international relations, keyboard course, france language course,
_________________________________
pray communities in every saturday, sunday school teacher
_________________________________
and i have a part time job as a marketing communication in every tuesday and friday after studying at college.
_________________________________
I also the one of the 60th Merry Riana Campus Ambassadors
_________________________________
Interest in politic, education, humanity and social civil development
_________________________________
_________________________________

HOURS EACH
MONTH
______________
______________
______________
______________
______________
______________

DATES OF
ACTIVITY
__________
__________
__________
__________
__________
__________

ACHIEVMENTS, AWARDS
AND LEADERSHIP POSITIONS
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

NAME OF
INSTITUTION
______________
______________
______________
______________
______________
______________

DATE
RECEIVED
__________
__________
__________
__________
__________
__________

TRAVEL TO OR LIVING OUTSIDE

YOUR COUNTRY (Country & City)
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

DATE

PURPOSE

______________
______________
______________
______________
______________

__________
__________
__________
__________
__________

What is your proficiency in English? (Choose from drop down list excellent,
good, fair or poor)
Reading

Excellent

Good

Fair

Poor

Writing

Excellent

Good

Fair

Poor

Listening

Excellent

Good

Fair

Poor

Speaking

Excellent

Good

Fair

Poor

Is English your native language? Yes

No

12 years
If English is not your native language, how many years have you studied English? _____

I have studied english

Where have you studied English? ________________________________

Additional Languages Spoken: _____________________________________

CURRENT ACADEMIC LEVEL OR YEAR __________________

2015

THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION

Melly Sabina Ester Lengkong

Applicant Name _______________________________

FORM 3. PERSONAL STATEMENT

Answer the following questions. You may only use the allocated space.
Why you would like to participate in this leadership and international cooperation program?
How does conflict among peoples affect your world, your country and your community?

Enter your essay here:

2015

THE HANSEN SUMMER INSTITUTE ON LEADERSHIP AND INTERNATIONAL COOPERATION

Melly Sabina Ester Lengkong

Applicant Name ________________________________________

FORM 4. ON LEADERSHIP
Answer the following questions. You may only use the allocated space.
4-1 Describe a situation in the past two years when you were in a leadership role. What aspect of this position was important
to you? Why?
4-2 What leadership skills would you bring to this program?
4-3 What does leadership mean to you?
4-4 How will participation in this program enhance your career goals?

Enter your essay here: