2015 Coca-Cola MENA Scholarship Program
Application Completion Checklist (Must be completed in
English)
Candidate Name(Full Name as it appears in passport)Nazim
Shahzad
Name of University(Currently enrolled in)COMSATS Institute of
Information Technology, Abbottabad.
Year of Study2015
Concentration Area of Study
Management Sciences
E-Mail Address
[email protected]
Home Address
Quarter # E-28, T&T Colony, Haripur Hazara, KPK.
Age23
GenderMale
City and CountryHaripur, Pakistan
Occupation
Student
In order for your application to be complete, please make sure
you submit:1. Completed Application Checklist Form (this page)1.
Completed Application (p 2-5)1. Completed Additional Information (p
6-12)1. Legible electronic copy of the picture/information page of
passport1. Copy of official transcript (please do not submit
original transcripts)
* All applications must be received via e-mail by February 6th,
2015. Any applications received after this time will not be
considered. Please e-mail applications to:
[email protected]
2015 Coca-Cola MENA Scholarship ProgramApplication Form
NAME: _Nazim
Shahzad_______________________________________________________________________
(First)(Middle)(Last name as indicated on passport)
CONTACT INFORMATIONMailing Address(if different from home
address) Quarter # E-28, T&T Colony, Haripur Hazara, KPK.
CellPhone0314-5085378HomePhone0995615552
WorkPhone
PERSONAL DATA
Gender Male Female
Date of Birth (Month, Day, Year)10, 19, 1991Place of Birth(City,
CountryWah Cant, Pakistan
Country of permanent legal residencePakistanCountry of
citizenshipPakistan
Dual Citizenship?Yes NoIf yes, indicate country
Year of Study (check one)1st Year 2nd year 3rd Year
** YOU MUST PROVIDE AN ELECTRONIC COPY OF THE
PICTURE/INFORMATION PAGE OF PASSPORT.
MILITARY STATUS (Men Only)
Check one Completed Exempt Non-Exempt N/A
** MILITARY EXEMPT PERMISSION FORMS MUST BE COMPLETED PRIOR TO
TRAVEL.
ENGLISH LANGUAGE PROFICIENCY
Number of years of English Study: Where Studied:
Reading proficiency (check one)Excellent Good Fair
Writing proficiency (check one)Excellent Good Fair
Speaking proficiency (check one)Excellent Good Fair
PREVIOUS ACADEMIC HONORS/SCHOLARSHIPS
Please indicate any scholarship, academic awards, or honors that
you have received and the year received:
NON-ACADEMIC/EXTRA-CURRICULAR ACTIVITIES
Please list community service, internships, professional
training, jobs, sports, or cultural activities in which you have
participated regularly in the past two years. This includes any
service as a team leader, council member, or officer in any
institution or activity.
Institution Name, City, CountryActivity and Your RoleDates of
ParticipationMM/YY MM/YY
From:
To:
From:
To:
From:
To:
TRAVEL EXPERIENCE
Please describe any previous travel or study outside of your
home country. (Please be sure to include any travel to the United
States for any reason)
Travel DatesMM/YY MM/YYTravel Purpose(e.g. vacation, school,
etc.)US GovernmentProgram? Y/N
From:To:
From:To:
From:To:
PERSONAL STATEMENT
Please answer the following essay questions in the box below.
Feel free to use more space if needed.
SHORT ESSAY #1: Why are you interested in participating in the
Global Business Institute-MENA program and what do you hope to gain
from it?
SHORT ESSAY #2: Identify one key challenge facing your country
today. What innovative idea would you apply to solving this
problem? Please describe what you would propose, including
examples, graphics and data as needed.
2015 Coca-Cola MENA Scholarship Program
Faculty Recommendation Form
Thank you for taking the time to complete this recommendation
form. This form gives us an idea of the students strengths and
weaknesses. Please return this completed form to the student in a
sealed envelope with your signature over the seal. He or she will
submit it along with their completed application.
Student Name
Faculty name and email
Faculty Signature
On a scale of 1 to 10 (1 being the lowest), rank the student in
the following qualities and include an explanation of your
score.Students motivation and maturity (please rank and
explain):
Students ability to handle ambiguity (please rank and
explain):
Students ability to collaborate in a team environment (please
rank and explain):
Describe one quality that you feel this student needs to improve
on (please explain):
MEDICAL HISTORY AND RELEASE
Participant Name
______________________________________________________________First
NameMiddle Name Last Name (as on passport)Emergency Contact
Information (All participants must complete this section of the
form.)Name
________________________________________________________Relationship
to Participant _____________________Phone
__________________________Alternate Phone ___________________Street
Address
________________________________________________________________City
_______________________ State/Province ____________Country
________________Email Address
_________________________________________________________________Participant
Medical HistoryAll participants must complete this section of the
form. If one does not apply to you, please list none.
Birth Date _____________Age ______Date of Last Tetanus Toxoid
__________Blood Type ____________Height ____________Weight ________
Do you smoke? Yes NoPast Health Concerns/Injuries
_____________________________________________________Present Health
Conditions_________________________________________________________Allergic
Reactions________________________________________________________________Present
Medications (Name, Dosage, Reason for Taking)
________________________________
____________________________________________________________________________________________________________________________________________________________
Please list any special conditions you are aware of or have been
told by a physician that we should be aware of (i.e., injuries,
past surgeries, arthritis, asthma, heart disease, high blood
pressure, pregnancy, etc.)
____________________________________________________________________________________________________________________________________________________I
hereby agree that the information provided above is true to my
knowledge.
________________________________________________________________Participant
SignatureDate
ASSUMPTION OF RISK AND RELEASE FROM LIABILITY
WHEREAS, The Trustees of Indiana University, through its Kelley
School of Business, department of Institute for International
Business is arranging field trips in Indiana for the purpose of:
business and U.S. cultural education throughout the Global Business
Institute from June 22 July 19, 2014 and WHEREAS, I,
______________________________, wish to participate in the Field
Trips, andParticipant Name
NOW THEREFORE, in consideration of University's services
rendered and services to be rendered in organizing the Field Trip
and in consideration of my participation in the Field Trip, I
hereby: 1.State that I understand that certain risks are inherent
in travel and that I fully accept those risks. These risks may
include, but are not limited to, such things as incidents related
to transportation, adverse weather conditions, and other physical,
mental, and emotional injury;
2.State that I understand that certain risks are inherent in
participation in field trips, and that I fully accept those risks.
These risks may include, but are not limited to, such things as
exposure to adverse weather conditions, sprains, broken bones,
cuts, bruises, entrapment, and other physical, mental, and
emotional injury;
3. State that I fully understand the risks and the scope of the
activities involved in the Field Trip, and I agree to assume the
risks of my participation in the Field Trip, including the risk of
catastrophic injury or death;
4. Release and fully discharge The Trustees of Indiana
University, its officers, agents and employees, from all liability
in connection with my participation in the Field Trip, for or on
account of any injury to or illness of my person or death, or for
or on account of any loss or damage to any personal property or
effects owned by me.
PARTICIPANT SIGNATURE: ___________________________
DATE: _____________________________
GBI PHOTO COMPOSITE
The GBI Photo Composite is a publication that will include
photographs and biographical information about each
participant.
Name
________________________________________________________________________first
name Middle Name Last Name (as Indicated on passport)Preferred Name
(If different than above) _____________________________________
Hometown (City, Country)
________________________________________________________
Academic Institution __________________________
Major/Concentration _______________
Personal Interests or Hobbies (list up to four)
_____________________________________________________________________
______________________________________________________________________
I give permission for my photo and biographical information to
be included in the GBI Photo Composite
_________________________________________________________________Participant
SignatureDate
PHOTO AND VIDEO RELEASEExampleName MohamedRaafatEl HabibyFirst
nameMiddle Namelast Name (As indicated on passport)
Preferred Name (If different than given surname) Mohamed
Raafat
Hometown (City, Country) Alexandria, Egypt
Academic InstitutionAin Shams University Major/Concentration
Engineering
Personal Interests or Hobbies (list up to four)
SwimmingReadingHikingFootball
Participant Name
______________________________________________________________first
name Middle Name Last Name (as Indicated on passport)I hereby grant
to Indiana University the right to reproduce, use, exhibit,
display, broadcast, distribute and create derivative works of
university related photographs or videotaped images of the
undersigned student for use in connection with the activities of
the university or for promoting, publicizing or explaining the
school or its activities. This grant includes, without limitation,
the right to publish such images in the universitys student
newspaper, alumni/ae magazine, on the universitys Web site, and
public relations/promotional materials, such as marketing and
admissions publications, advertisements, fund-raising materials and
any other university-related publication. These images may appear
in any of the wide variety of formats and media now available to
the school and that may be available in the future, including but
not limited to print, broadcast, videotape, CD-ROM and
electronic/online media. All photos taken are without compensation
to me (the undersigned). All electronic or non-electronic
negatives, positives, and prints are owned by the university. I
hereby acknowledge that I have read and understand the terms of
this release.
____________________________________________
_____________________Participant SignatureDate
ADDITIONAL INFORMATION
Participant Name
______________________________________________________________first
name Middle Name Last Name (as Indicated on passport)
Dietary Preferences, Allergies and Restrictions (Please check
all that apply)
No Fish Vegetarian Halal
Dairy-Free (Lactose Intolerant)
Other ______________________________________
Check here if you have special needs that might require
accommodations to fully participate in the program. A staff member
will contact you.
T-Shirt Size (American t-shirt sizes are typically one size
larger. For example, if you normally wear a large indicate medium
below)
Extra Small Small Medium Large Extra Large Extra Extra Large
Bradford Woods--Indiana Universitys Outdoor CenterParticipation
Agreement
Program Name: Global Business Institute Program Dates: June,
2015
Please fill out this form thoroughly. We will use the
information provided to plan a safe and enjoyable experience. This
also serves as a helpful reminder to you of physical precautions
and care you may need to take because of previous injuries and
other physical conditions you may have. Any information disclosed
on this form will remain confidential.
Participant Information:
Name_____________________________________________________________________
Male Female
Address__________________________________________________________
Date of Birth______/_______/_______
City______________________________ State_________ Zip______________
Phone (______) __________________ In Case of Emergency: Notify
(Name):__________________________________________ Relationship to
participant ____________________ Address
__________________________________________________________ Phone
(______) __________________ Name of
Physician__________________________________________________ Phone
(______) __________________ Physicians
Address___________________________________________________________________________________________
Insurance Company___________________________________ Policy
Number_________________________________
Medical Information: Blood Type________ Height________
Weight________
Allergies_____________________________________________ Describe
allergic reaction:
____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________Specific
Dietary needs:
______________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
Current medications (name, dosage, reason for taking):
_____________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
Please list any special conditions you are aware of or have been
told by a physician that we should be aware of (i.e., injuries,
medical diagnosis, past surgeries, arthritis, asthma, heart
disease, high blood pressure, pregnancy, etc.)
__________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
Medical Services Permission ReleaseDuring the participation in a
Bradford Woods program, the Trustees of Indiana University, its
agents, servants, and employees are hereby authorized to provide
and secure any medical services, and authorize the diagnosis and
treatment (including, but not limited to, surgery and the
administering of anesthesia) of any injury or illness as in its
judgment is necessary or advisable for the individual. I hereby
agree that the MEDICAL HISTORY provided above is true to my
knowledge. I declare that I have read and understand the contents
of this MEDICAL SERVICES PERMISSION and I am signing this as my
free and voluntary act, irrevocably binding myself and my
heirs.
______________________________________________________
___________________________ Participant Signature (Legal guardians
signature if participant is under 18) Date Global ReleaseProgram
Name: Global Business Institute Program Dates: June, 2015Indiana
University, through its Bradford Woods programs (hereinafter
referred to as University), manages and conducts adventure and
outdoor based programs consisting of but not limited to: ground
based initiatives, individual and group challenge activities, low,
intermediate, and high ropes courses, hiking, camping, backpacking,
caving, canoeing, other water based activities, fishing, archery,
arts and crafts, environmental nature studies, service projects,
transportation to and from activity sites and all other activities.
These activities are supervised by University staff, interns, and
school personnel. Although novice skills will be taught and
supervised by competent and experienced adult leaders, there is
some degree of risk involved in the various activities and the
ultimate safety of each participant will depend on the participants
willingness to listen and to abide by the instructions, rules, and
regulations given throughout the program. The safety and well-being
of each participant is of paramount importance to Bradford Woods
and the professional staff, employees, and trustees of Indiana
University. All reasonable care and precautions are taken to ensure
a fun educational experience. The following acknowledgment,
assumption of risk and release of claims is both a requirement of
insurance coverage and an important reminder to you as a parent /
guardian or participant to be sure that you or your child is
properly prepared. Acknowledgement, Assumption of Risks and Release
of Claims ReleaseI, or my child desire to participate in the
program specified above. I understand the program offered through
Bradford Woods will take place in a wilderness environment and may
include, but is not limited to, the following potential hazardous
activities: ground based initiatives, individual and group
challenge activities, low, intermediate, and high ropes courses,
hiking, camping, backpacking, caving, canoeing, other water based
activities, fishing, archery, arts and crafts, environmental nature
studies, transportation to and from activity sites and all other
activities. The inherent risks of these activities include the
following: personal injury, property damage, illness, or death. I
understand that Bradford Woods does not require that I participate
in the above-mentioned program. In recognition of the potentially
hazardous nature of the elective program, I, or my child, my heirs
and assigns, hereby release Bradford Woods and the professional
staff, employees, the trustees of Indiana University, and its
agents from all claims of negligence arising from participation in
the program. I further agree to hold harmless and indemnify
Bradford Woods and the professional staff, employees, the trustees
of Indiana University, and its agents for all defense costs,
including attorney fees, and any other costs resulting in
connection with my participation in this program. I understand that
this release relates to all claims and liability during and after
the program resulting from a pre-existing medical condition. I have
read and completed the medical history form provided by Bradford
Woods and accept full responsibility for omissions or errors on the
medical history form. I also understand that this release relates
to all claims and liability resulting from unforeseen or
intemperate weather. I have read the clothing list provided by
Bradford Woods and accept full responsibility for inadequate
clothing provided by me or those items which I fail to provide. I
have read this entire acknowledgement and assumption of risk and
release of claims and fully understand the contents. My signature
indicates that I have satisfied my questions and concerns regarding
the above-mentioned program by talking with a representative of
Bradford Woods.
___________________________________________________________
_________________________ Participant Signature (Legal guardians
signature if participant is under 18) Date
Photographic ReleaseI hereby grant the University permission to
take photographs, video recordings, and/or sound recordings of
myself or my son or daughter. I grant the university permission to
use the negatives, prints, motion pictures, video tapings, or any
other reproduction of the same for educational and promotional
purposes in manuals, on flyers, on the internet, or in any other
manner deemed necessary. I declare that I have read and understand
the contents of this PHOTOGRAPHIC RELEASE, and I am signing this as
my free and voluntary act, irrevocably binding myself and my
heirs.
____________________________________________________________
_________________________ Participant Signature (Legal guardians
signature if participant is under 18) Date
Classified - UnclassifiedClassified - Unclassified
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified