Embassy of the United States Moscow, Russia

(To fill out this registration form, please copy and paste this text into a word processing program)

A. Last (family) name as on passport:

B. First name as on passport:

C. Middle name(s) as on passport:

D. Date of birth (month/day/year):

E. City of birth:

F. Country of birth:

G. Country of residence:

H. Country of citizenship:

I. Gender:

J. Position (Choose from "Secondary School Student", "University Undergraduate Student", or "Special School, Institute, or Vocational Student". If in the gap year between high school and college, use the “Secondary school student” position and explain in detail.)

K. Full address:

L. Home telephone number:

M. E-mail address(es):

N. Medical, physical, dietary, or other personal considerations:

O. Name of high school or college/university:

P. Field of study (if applicable):

Q. Any other relevant educational, academic and professional experience or training:

R. Active memberships, special interests, or extracurricular activities:

S. Previous travel or study experience in the United States (Please include dates and purpose):

T. Future study or career plans: