attachments in order for your Cabanillas 1. Last name (family name): Sifuentesapplication to be reviewed. 2.

Home address: name): Carlo Eloy 3. First name (given Type home address as it should appear on an envelope: Calle Cavero y Muoz # 466 Urb. Las Postal Code: +051 Phone number: -Per 4. Quintanas Trujillo044-297098 Work address: Fax number: -----Type workCode: ------it should appear on an envelope: -----Postal address as Phone number: ------5. Which address would you prefer we send mail to? HOME Fax number: ------6. Email address: carloeloy_sc@hotmail.com 1

Year Twelve: Developing Community Leaders International Fellowship 20, 2012 Wednesday, May 30 Wednesday, Juneof the Applications welcome from citizens and residents of: Albania, Bolivia, 92nd Street Y Democratic Republic of Congo, Ecuador, Haiti, India, Israel, Application Form You must be fluent in English to be considered for admission. Please type or Mongolia, Peru, Tunisia, Zambia print, complete the application form in its entirety, and supply all necessary Personal Information

Ford Motor Company

7. 8. Date of birth (month/day/year): 03/02/1989 9. Sex: MALE 12. Please indicate two emergency contacts: 10.A) Original language: Spanish Name: Eloisa Petronila Cabanillas Benites Phone number: +511949447814 11. OtherRelationship Cavero Sifuentes #English): French and Chinese languages Carlos Mother Address: Callespoken (aside fromAyala Urb. Las Quintanas Trujillo -Per B) Name: Jorge to you: y Muoz 466 Do Address:number: passport? Yes I# 466 Urb. Las Quintanas Trujillo -Per you have Calle Cavero y Muoz do Phone a valid +511949970250 Relationship to you: fellowship? 13. How did you hear about thisFather The institute where I studied English called El Cultural send me an e-mal with this Educational Background information. 14. Please indicate certification programs that you have completed or are currently pursuing: Name of school: El Cultural City: Trujillo Country: Peru Date completed: 3 Years Area of study: English Type of degree: Advanced Honors, awards, other: ------Name of school: Sencico City: Trujillo Country: Peru Date completed: 3 months Area of study: Autocad 2D Type of degree: Profesional Honors, awards, other: ---------

all degree or

15. Current or most recent position: Type of job/title: Supervisor Responsibilities: Quality control of products, Name of organization: Parrilladas El Potrero Address of organization: Av. Manuel Vera Enriquez 575 Urb. Las Quintanas Trujillo - Peru Dates of employment: Since 01/29/2005 up today Full or positions Part Time 16. Previouspart time? [list each]: Type of of employment: Dates job/title: Responsibilities: Full or part time? Type of job/title: Name of organization: Responsibilities: Dates of employment: Address of organization: Name of organization: Other Relevant Experience Full or part time? Address volunteer experience, community involvement, etc. 17. Describe anyof organization: Improved the quality of life in small town in the highlands 3

Employment History

18. Do you have any physical, emotional, or psychological conditions that we should be aware of? Not 19. Do you have any dietary restrictions and/or allergies? If so, please describe: 20. Do you have health and/or medical insurance? Type of coverage: References Provider: 21. Please enclose two letters of recommendation in envelopes sealed and signed Policy the seals across Name: by your references, or ask your references to post-mail or email A. number: their letters directly and privately to fordfellowship@92Y.org. Each letter should B.Title: Name: be written by an employer, educator, or counselor who has known you in a Organization name: Title: professional or academic capacity for more than six months. Letters from Address: Organization name: personal references (family members or friends) will not be accepted. Please list City: Address: your two references below so that we may contact them. Country: City: Postal Code: Country: Phone Code: Postal number: Fax number: Phone number: Email address: Fax number: Email address:

Health and Medical Information

22. Do you have access to a computer and the Internet? Where? YES I DO, AT HOME Other Fellowships 23. Are you currently a recipient of another fellowship? 24. HaveNot been a fellowship recipient in the past? Not you If so, what was the name and nature of the program? Attachments Please include the following attachments with your completed application form: Cover Letter. Include how you learned about the Ford Motor Company International Fellowship of the 92nd Street Y. Resume or Curriculum Vitae Two-page Essay. In narrative form, describe your background and your reasons for wanting to participate in this program. Also, describe in detail issues affecting the well-being and stability of your community. (Examples include inter-group conflict, community health concerns, youth development, and environmental matters.) Then answer the following questions: What outcome do you hope for? What role do you wish to play in that outcome? What skills do you feel you need to make the desired outcome happen? Two Reference Letters. Letters should be written by professional or academic references. They may be enclosed with your application in envelopes sealed and signed across the seals by your references or sent separately and privately by your references. (For more information, please see the References section on the previous page.)

Computer Access

APPLICATIONS MUST BE EMAILED OR POSTMARKED BY June 30, 2011. You will be notified of receipt of your application, and you will be apprised of the status program is a rigorous learning2011. This of your application by December 31, opportunity. It requires completion of reading, writing, and group assignments prior to and following the Submit your completed application along with all required attachments to: fordfellowship@92Y.org residency, to: participation in all classes and group activities while in New Or post-mail full York,Motor Company International Fellowship of the 92nd Street Y as we Ford and a commitment to remain involved in the programs future For information and queries: build Motor Company reserves the rightleaders throughout the world. 92nd Street YM-YWHA Phone:a growing network of community to information from this application for Ford 212.415.5473 1395 212.415.5798 YM-YWHA is an agency of UJA-Federation. Fax: 92nd Street theirLexington Avenue The internal tracking purposes. New York, NY 10128 Email: agardy@92Y.org 6 USA Website: www.92Y.org/ford

Deadline for Submission