FELLOWSHIP FOR EMERGING LEADERS IN PUBLIC SERVICE Office of Student and Program Services The credit cards accepted for program payment are: VISA, MasterCard, and American Express. All fields marked with are required. Fellowship Participant Information Fellow First Name Fellow Last Name Fellow Work Email Work Organization Contact Information for the Person Making the Payment First Name Last Name Organization (if applicable) Address City State Non-US AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Country United States Afghanistan Albania Algeria American Samoa (US) Andorra Angola Anguilla (UK) Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda (UK) Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands (UK) Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands (UK) Central African Republic Chad Chile China Christmas Island (AU) Cocos (Keeling) Islands (AU) Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands (NZ) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (UK) Faroe Islands (DK) Fiji Finland France French Guiana (FR) French Polynesia (FR) Gabon Gambia Georgia Germany Ghana Gibraltar (UK) Greece Greenland (DK) Grenada Guadeloupe (FR) Guam (US) Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City) Honduras Hong Kong (CN) Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Korea, Democratic People's Republic (North) Korea, Republic of (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau (CN) Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall islands Martinique (FR) Mauritania Mauritius Mayotte (FR) Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat (UK) Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles (NL) New Caledonia (FR) New Zealand Nicaragua Niger Nigeria Niue Norfolk Island (AU) Northern Mariana Islands (US) Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands (UK) Poland Portugal Puerto Rico (US) Qatar Reunion (FR) Romania Russia Rwanda Saint Helena (UK) Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon (FR) Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Islands (UK) Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands (UK) Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (US) Wallis and Futuna (FR) Western Sahara Yemen Zambia Zimbabwe Payer Email Billing Phone Payment Information The program fee must be paid in full by October 26, 2023 for accepted candidates to participate in the fellowship. Full payment* $650 Partial payment: Remainder will be paid separately by: Credit card Personal check Organizational check Cancellation Policy No refunds are available after the payment has been submitted. I have read this statement and I agree to these terms. Date: (MM/DD/YYYY)