Sample IVLP Nomination Form

1. Full name (as per passport)

2. Age
3.        Date of birth
4. Place of birth (as per passport)

5.        Position title and work contact information

Position – Organization:
Address:
Tel office:
Tel residence:
Mobile office:
Mobile personal:
Email office:
Email personal:

6.        Concurrent and/or previous positions

2000 – Indicate “present” or year” : Position, Organization
2000 – Indicate “present” or year” : Position, Organization
2000 – Indicate “present” or year” : Position, Organization
2000 – Indicate “present” or year” : Position, Organization

7.        Education
Year: Degree, Institution
Year: Degree, Institution
Year: Degree, Institution

8. Previous U.S. travel

Yes     No
Year: Cities, Purpose of Travel
Year: Cities, Purpose of Travel

For the following, please be as detailed as possible. If there is more information beyond
the questions listed below, please add details that will help with the nomination
process:
9.      How have you demonstrated leadership potential in your field to date?
10.        Why do you feel you are the perfect fit for this IVLP project?
11.    Where do you expect to be in 10 years?
12.    How will you utilize what you learned when you are back in India? How will
others be impacted by your participation?
13.    What is the multiplier effect of your participation?
14.    How will your participation further your professional goals?
15.    Provide some examples of your work that match the IVLP project.