University Scholarship Program (USP V)

American University of Beirut, Office of Admissions | PO Box 110236, Riad El Solh, 1107 2020, Bliss Street, Beirut, Lebanon | Tel: +961-1-374374/374444 ext: 2585/2590/2596/3505
[email protected] | www.aub.edu.lb/usp | For information on the United States Agency for International Development (USAID) kindly visit the following website: www.usaid.gov/lebanon
University Scholarship Program (USP V)
Application for Undergraduate Study for the Academic Year (2014-15)
American University of Beirut | Office of Admissions, Beirut, Lebanon
Documents Required – CHECKLIST
If you are interested in being considered as a candidate in the
USP V scholarship program, please submit all the following
required documents with this application form completely
filled out in dry ink to the AUB Office of Admissions.
This checklist is for you to ensure inclusion of all needed
documents. Any missing document will jeopardize processing
your application. Incomplete applications will not be
considered. Therefore, all items requested below (when
applicable) must be submitted with the application form.
1. USP V Application must be submitted to AUB Office
of Admissions prior to March 31, 2014 (deadline).
2. USP V Application form must be completed and filled
out in dry ink only.
3. Official high school grades for the last two school
years (G10 or BT1 and G11 or BT2) in a sealed
stamped envelope
4. Two passport size color photographs taken within a
period of six months
5. A copy of national identity card or a copy of ‫إخراج قيد‬
6. Employment records:
a.
Recent employment certificate (s) for job(s) held
by each earning family member clearly stating
occupation, job title, years of service, number
of months payable, and benefits (educational
benefits, accommodation, health)
b.
Attached employee income statement Form A:
filled out, signed, and stamped by employer
for each earning family member. If working in
public sector, the official income statement
issued by the government should be submitted
(monthly payroll slip is not a valid document).
c.
Attached self-employed income statement
Form B: filled out, signed, and stamped by
self-employed family member. Form should be
submitted with the business registration (‫سجل‬
‫)تجاري‬, income tax statements (‫)ضريبة دخل‬, and
business bank statement of account for the last
three years.
If not applicable, please provide letter from ‫ مختار‬detailing
your financial status.
7. A recent school certificate of registration showing
annual tuition fees and receipt of fees for each
dependent child enrolled at school or university
must be submitted with the application.
8. A recent family civil status record issued within
a period of three months (‫ )اخراج قيد عائلي‬must be
submitted with the application.
9. A copy of recent rental or ownership land and/or
house contract (or any other premises) must be
submitted with the application.
10. A certificate of ownership in the name of the father
and mother must be submitted with the application.
This certificate should be obtained from the Land
Registry Department in Beirut and in the caza where
the family is registered (Ministry of Finance located
in Khandak el Ghamik area, near Fouad Shehab
Bridge, Moukarzel Building, 9th Floor).
11. A copy of car/vehicle registration form (for each
owned vehicle/car) must be submitted with the
application, if applicable.
12. A copy of loan agreement (s), if any, must be
submitted with the application, with needed
supporting documents.
13. Bank statement certificates of savings must be
submitted with the application, if applicable.
14. Any additional document deemed necessary to
support your financial aid application must be
submitted, i.e., medical report, certificate of job
termination, or end of service.
NOTES:
Applications received after the deadline – March 31, 2014 –
will NOT be considered.
Applications have to be submitted to the AUB Admissions
Office prior to the March 31, 2014 deadline and not mailed
by the schools (as this might cause a risk of delay in
submitting applications prior to the deadline).
Failing to attend an orientation day event, interview, or
EEE exam will jeopardize a student’s consideration, even if
shortlisted.
Each application received prior to the deadline will be given
an application number (by the AUB Admissions Office) which
will be the ID number of the student.
All shortlisted acceptances will be posted on the website by
ID number. (http://www.aub.edu.lb/usp/Pages/index.aspx)
Applicants may use this site to track their status.
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University Scholarship Program (USP V)
Application for Undergraduate Study for the Academic Year (2014-15)
University Scholarship Program (USP V)
Application for Undergraduate Study for the Academic Year (2014-15)
American University of Beirut | Office of Admissions, Beirut, Lebanon
American University of Beirut | Office of Admissions, Beirut, Lebanon
)‫جدول بالوثائق المطلوبة لبرنامج المنح الدراسية الجامعية (الخامس‬
The application should be filled out in dry ink only; applications written in pencil will be not be considered.
The Program
:‫إسم الطالب‬
)2( ‫ صورة فوتوغرافية‬
‫ إخراج قيد إفرادي جديد للطالب‬
:))‫ (رسالة توضيحية (ر ت) من رب العمل باإلضافة إلى تصريح بالراتب (ت م‬:‫ عقد العمل الحالي ومضمونه‬
The University Scholarship Program V (USP V) is a scholarship program established at the American University of Beirut (AUB)
with the support of the American people through the United States Agency for International Development (USAID). The program
offers university-bound students a unique opportunity to pursue quality higher education. The program targets Lebanese public
schools and technical school graduates from the 26 districts of Lebanon. The scholarship will fully support 52 qualified students
toward their undergraduate degrees. Student beneficiaries will experience AUB’s high/rigorous academic standards and a campus
environment that promotes gender and social equality and critical thinking.
Eligibility Requirements
‫ األب‬
Public Schools
‫ األم‬
To be eligible to apply to the USP V program, students are required to
:‫ أعضاء أخرى من العائلة‬
•
be Lebanese nationals,
•
have attended a regular public school in Lebanon for the last three years through the high school level and expect to
join AUB in Fall 2014-15,
• show high academic achievement in their first secondary (G10) and second secondary (G11) years,
• demonstrate high financial need,
‫ صور عن الوثائق الرسمية المبينة لتوزيع الحصص في الشركات الخاصة‬
‫ البيانات الرسمية لضريبة الدخل والميزانية العامة المقدمة لوزارة المال عن العمل الخاص‬
‫ صور عن وثائق الملكية المؤجرة مع عقود اإليجار الحالية‬
•
demonstrate evidence of leadership qualities and engagement in community service,
•
apply to and be accepted as full time students at AUB,
•
earn a minimum score of 12/20 on the official Lebanese Baccalaureate exam,
•
sit for AUB’s English Entrance Exam (EEE) to determine the level of their knowledge of verbal and written English
(Results of the EEE will be used to place the students in preparatory, remedial, or regular English. AUB will cover the
fee of the EEE.),
‫ مستندات بالمدفوعات المدرسية السنوية لكل من األوالد المسجلين في المدارس أو الجامعات‬
‫ وثائق رسمية للمستحقات أو المساعدات التعليمية‬
)‫ إخراج قيد عائلي (فترة اصداره ال تزيد عن الستة أشهر‬
Technical Schools
To be eligible to apply to the USP V program, students are required to
‫ أما في حل إستعمال عقار أحد األقرباء أو‬.)‫ صور عن عقود اإليجار الحديثة (أو ايصاالت رسمية في حال عدم توفر العقد عن السنة الحالية‬
‫العمل‬
‫البيت‬
:‫األصدقاء عندها يجب تسليم عقد ايجارهم أو صك الملكية‬
•
be Lebanese nationals,
•
have attended a regular technical public school in Lebanon through the secondary school level (BT1, BT2, BT3) and
expect to join AUB in Fall 2014-15,
•
show high academic achievement through their years (BT1, BT2) of technical baccalaureate formation,
‫ صور عن الوثائق الرسمية عن اتفاقيات القروض‬
•
demonstrate high financial need,
‫ صور عن وثائق التأمين الصحي‬
•
demonstrate evidence of leadership qualities and engagement in community service,
)‫ (مع تحديد نوعيتها‬:‫ صور عن مستندات أخرى‬
•
apply to and be accepted as full time students at AUB,
•
earn a minimum score of 12/20 on the technical official technical Lebanese Baccalaureate exam,
•
sit for AUB’s English Entrance Exam (EEE) to determine the level of their knowledge of verbal and written English.
(Results of the EEE will be used to place the students in preparatory, remedial, or regular English. AUB will cover the
fee of the EEE.),
‫ صور عن وثائق الملكية (المشتراة أو الموروثة) أو تلك التي بإسم المالك األساسي إذا لم يتم تسجيلها بعد‬
‫ أشياء أخرى‬
‫ العمل‬
‫ البيت‬
‫سلمت المستندات إلى‬
‫االمضاء‬
2 of 18
‫بتاريخ‬
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Detach and mail to AUB
Paste recent colored
passport-size photograph.
Do not staple.
Selection Process
Shortlisting of Applicants
University Scholarship Program (USP V)
Application for Undergraduate Study for the Academic Year (2014-15)
American University of Beirut | Office of Admissions, Beirut, Lebanon
Students candidates will be short listed based on a composite score of financial need and 10th (for technical baccalaureate: BT1)
and 11th (for technical baccalaureate: BT2) grades’ averages. The selection of the candidates will take into account the geographical
distribution by district.
The application should be filled out in dry ink only. Applications written in pencil will be not be considered
Biographical Information
Final Selection
Full legal name: Mr./Ms./Miss The shortlisted applicants will be invited to AUB for an Orientation Day. During that day the selected students will sit for the EEE
exam, tour the campus, and be interviewed by members of the Selection Committee to validate financial aid applications and
leadership skills.
30 %
(Taking into account geographical distribution by district)
Official Baccalaureate exam results: 30 %
Interview (for validation of financial aid and leadership skills):
25 %
EEE exam results: 15 %
Estimated Timeline
Program objectives to be achieved
December 2013-March 2014
Advertise the Program
Visit Public and Technical Lebanese Schools
March 31, 2014
April 2014
May 2014
June 15, 2014
July 2014
July 2014
July-August 15, 2014
August 25-29, 2014
September 2014
Application Deadline
Review of Applications
AUB Orientation Day
Deadline for Change of Majors
Announcement of Official Baccalaureate exam results
Final selection of 52 USP V scholars
Final confirmation of acceptance of the USP V scholars
USP V Orientation
Start of New Academic Year
Middle (or father’s name)
/
Suffix (Jr., Sr.)
(Full name as it appears on passport or identity card)
Current Mailing Address (permanent/home address):
The final selection percentage distribution:
Projected Work Plan
/
First
In Arabic Composite score of financial need and 10th and 11th grade averages: /
Last
/
Building/FloorStreet
/
PO Box (not AUB box)
Telephone (home): /
Area/Caza
Country code
/
District
/
/
City
/
Area code
Number
/
Zip Code
(cell): Country code
Country
/
Area code
/
Number
Please tick one of the boxes depending on your preference of stay when studying at AUB:
Housing for long commute
Transportation allowance
Email address: Gender:
Male
Date of birth: @
Day
Marital Status:
Female
/
Month Single
/
Year
Engaged
Married
Divorced
Widowed
Provide details of any plans for marriage: Country of Birth: Nationality:
Lebanese
Other (Please specify) Are you:
an American Citizen
a Green Card Holder
an Asylum Seeker
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List of Academic Programs for Technical Baccalaureate Students
Detach and mail to AUB
Choose up to three majors, if possible. Please assign priorities to your choices (1 - most preferred, 3 - least preferred).
Academic Programs
available majors and fields of study
Lebanese Technical Baccalaureate
Domain
Industrial nutrition
Agriculture
A. List of Academic Programs for Regular
Baccalaureate Students:
Health Supervisor
Nursing Care
Dentist Assistant
Choose up to three majors. Please assign priorities to your
choices (1 - most preferred, 3 - least preferred).
Faculty of Agricultural and Food Sciences (FAFS)
Agribusiness BS-AGBU
Agriculture BSA-AGRI
Food Sciences and Management BS-FSMT
Landscape Design and Eco-Management BSL-LDEM
Nutrition and Dietetics BS-NTDT
Notes:
Suliman S. Olayan School of Business (OSB)
http://www.aub.edu.lb/fas/fas-home/student-resources/
Pages/useful-forms.aspx
Faculty of Engineering and Architecture (FEA)
http://www.aub.edu.lb/registrar/Documents/pdfdoc/
doublemajor-application.pdf
Business Administration BBA-BUADM
Architecture BAR-ARCH
Graphic Design BFA-GRDP
Civil Engineering BEN-ECIV
Construction Engineering BS-CONS
Computer and Communication Engineering BEN-ECMP
Chemical Engineering BEN-CHME
Chemical Engineering BS-CHME
Electrical and Computer Engineering BEN-EECE
Mechanical Engineering BEN-EMCH
Faculty of Health Sciences (FHS)
Air Conditioning
Elevators
Construction and Public work
Landscaping
Industrial Mechanics
Car Mechanics
Aero Mechanics
Sewage Mechanics and Heating
Electricity
Electronics
Information Technology
Electro – Technical
Computer Programming
Industrial Electricity
If you want to enroll in a minor (a minor is a less intensive
course of study that is secondary to the major and
supplement it), teaching diploma, or double major, check
the following links:
Eligible to Apply to
Numbered Priority of Majors
Faculty of Agricultural and Food Sciences
Food Sciences and Management
Nutrition
Agriculture
Agri-Business
Faculty of Health Sciences
Medical Laboratory Sciences
Environmental Health
Medical Imaging Sciences
Hariri School of Nursing:
Nursing
Faculty of Engineering and Architecture
Civil Engineering
Construction Engineering
Mechanical Engineering
Faculty of Engineering and Architecture
Mechanical Engineering
Faculty of Engineering and Architecture
Electrical and Computer Engineering
Faculty of Engineering and Architecture
Chemical Engineering
Industrial Chemistry
List the secondary schools you have attended in the last three years:
Medical Laboratory Sciences BS-MLSP
Environmental Health BS-ENVH
From
(dd/mm/year)
Name of School
To
(dd/mm/year)
Grade
District/
Mouhafaza
City
Phone number
Faculty of Arts and Sciences (FAS)
Biology BS-BIOL
Chemistry BS-CHEM
Computer Sciences BS-CMPS
Economics BA-ECON
Education/Elementary BA-EDU-EEDU
Petroleum Studies BS-PTST
Political Studies BA-POLS
Public Administration BA-PUBA
Statistics BA-STAT
Statistics BS-STAT
Studio Arts BA-SART
Hariri School of Nursing
Bachelor of Science in Nursing BSN-NURS
Date of Graduation: /
/
Day/Month/Year
Type of Baccalaureate Certificate:
General Sciences
Life Sciences
Sociology and Economics
Technical baccalaureate (Please specify specialty)
Name of contact in case of emergency: /
NameRelationship
/
6 of 18
Literature and Humanities
Building/FloorStreet
/
PO Box (not AUB box)
/
Area/Caza
/
District
/
City
Zip Code
/
Country
7 of 18
Please include in the space below a letter of one page explaining why you are choosing these majors according to your listed
priority of preference, and how you would benefit your district and country by joining any one of the chosen majors. This letter,
explaining your choice of majors, is mandatory, otherwise you will jeopardize processing your application and your application will
not be considered.
Additional Information
Are you planning to apply to Military Academy?
Have you applied or are you planning to apply to other scholarship programs? If yes, please specify.
Do you have another plan/alternative in case you are not accepted for the USP V scholarship at AUB?
Has any family member benefitted from a USP program?
Name: Institution:
Year:
Health Information
Please indicate if you have any physical/learning disability. (Please note that this question relates to an
illness or a medical condition that leads to a disability and it is not intended to discriminate against illness
or disability, but to better serve the student.)
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9 of 18
Financial Information
Father
/
/
Last
Occupation:
First
Self-employed
/
Middle (or father’s name)
Employed
Unemployed
Suffix (Jr /Sr)
Name
Age
Relationship
Education/Occupation
Age
Relationship
Education/Occupation
Age
Relationship
Education/Occupation
Age
Relationship
Education/Occupation
Deceased
Please specify job if self-employed or employed
Name
Job Address (if employed or self-employed):
Telephone (work): / Country code
/
Area code
/
Number
(cell): Country code
/
Area code
/
Name
Number
Please indicate father’s annual income (annual salary or income and benefits) in Lebanese pounds:
(Please attach income statement)
Name
Family Household Income Information
Mother
/
/
Last
Occupation:
First
Self-employed
Employed
Income in 2013
Business
Farming
Real estate holdings
Securities (stocks and bonds)
Income of other members of the household(please specify)
/
Middle (or father’s name)
Unemployed
Suffix (Jr /Sr)
Deceased
Please specify job if self-employed or employed
Family Household Expense Information
Job Address (if employed or self-employed):
Telephone (work): / Amount in L.L.
Country code
/
Area code
/
Number
(cell): Country code
/
Area code
Income in 2013
Loans or installments
Education tuition for dependents/tuition fees
Please attach statements of tuition for all dependents.
Other expenses (please specify)
/
Number
Please indicate mother’s annual income (annual salary or income and benefits) in Lebanese pounds:
Amount in L.L.
(Please attach income statement)
Does your family own your home or apartment?
How many people, including yourself, depend on the income of your parent(s) for daily living expenses?
List all family members living at home and their current employment status (Please attach Family Civil Status Record):
Yes
No
If yes, please indicate current home value converted to Lebanese pounds.
Location of your home (please provide necessary documents)
Name
Age
Relationship
Education/Occupation
If yes, please indicate location Age
Relationship
Education/Occupation
No
and value converted to Lebanese pounds. Please provide the registration form for all owned cars, if any.
Make (Model) 10 of 18
Yes
How many cars does your family own? Name
Do you or your family own any land or have any asset(s)?
Year Owner Value (L.L.) 11 of 18
‫العائلي‪:‬‬
‫المادي‬
‫معلومات عن الوضع‬
‫ّ‬
‫ّ‬
‫معلومات ماد ّية‬
‫المهنة‪:‬‬
‫ مهنة ح ّرة‬
‫موظف‬
‫ ّ‬
‫ آليعمل‬
‫ متوفي‬
‫كموظف أو صاحب مهنة ح ّرة‪ :‬‬
‫ال ّرجاء تحديد المهنة اذا كان األب يعمل‬
‫ّ‬
‫عنوان العمل‪ :‬‬
‫هاتف‪ :‬‬
‫‬
‫دخل سنىة ‪2013‬‬
‫‪Detach and mail to AUB‬‬
‫أألب الثالثي‪ :‬‬
‫إسم ّ‬
‫تجارة‬
‫زراعة‬
‫ملكية خاصة‬
‫ضمانات‬
‫دخل اضافي من أحد افراد أألسرة‬
‫خليوي‪ :‬‬
‫السنوي لألب ( المعاش السنوي ‪ +‬تعويضات ‪ +‬منح ( إذا وجد) ) ‪:‬‬
‫الدخل ّ‬
‫الرجاء تحديد ّ‬
‫‬
‫العائلي‪:‬‬
‫معلومات عن مصروف‬
‫ّ‬
‫ليرة لبنانية‬
‫مصروف سنىة ‪2013‬‬
‫المهنة‪:‬‬
‫ل‪.‬ل‪.‬‬
‫قرض شخصي‬
‫األم الثالثي‪ :‬‬
‫إسم ّ‬
‫ مهنة ح ّرة‬
‫ل‪.‬ل‪.‬‬
‫موظف‬
‫ ّ‬
‫ آليعمل‬
‫أقساط مدرس ّية ‪/‬جامع ّية‬
‫ متوفي‬
‫مصروف أخر‬
‫كموظفة أو صاحبة مهنة ح ّرة‪ :‬‬
‫ال ّرجاء تحديد المهنة اذا كانت األم تعمل‬
‫ّ‬
‫هل تمتلك عائلتك المنزل الذي تعيش فيه؟‬
‫عنوان العمل‪ :‬‬
‫هاتف‪ :‬‬
‫‬
‫حدد القيمة الشرائية للمنزل‬
‫إذا نعم‬
‫ّ‬
‫خليوي‪ :‬‬
‫ليرة لبنان ّية‬
‫(حددي ) موقع البيت ( المنطقة)‬
‫حدد ّ‬
‫ّ‬
‫السنوي لألم ( المعاش السنوي ‪ +‬تعويضات ‪ +‬منح ( إذا وجد) ) ‪:‬‬
‫الدخل ّ‬
‫ال ّرجاء تحديد ّ‬
‫‬
‫ نعم‬
‫ كآل‬
‫(أنت) تمتلك ( تمتلكين) امالكأ شخصية أخرى؟‬
‫هل أنت ِ‬
‫ليرة لبنانية‬
‫المحدد أعاله‪ :‬‬
‫الدخل السنوي‬
‫ّ‬
‫حدد عدد األشخاص الذّ ين يعتاشون من ّ‬
‫ّ‬
‫ كآل‬
‫ نعم‬
‫الجفرافي‪:‬‬
‫حدد ما هي هذه الممتلكات‪ ،‬قيمتها الماد ّية بالليرة الللبنانية وموقعها‬
‫ّ‬
‫إذا كان جوابك نعم ّ‬
‫‬
‫أذكر ( أذكري) عدد أفراد عائلتك الذين يعيشون معك في المنزل‪:‬‬
‫‬
‫‬
‫‬
‫‬
‫العمر‬
‫‬
‫األسم‬
‫‬
‫العالقة العائلية‬
‫علمي‪/‬مهنة‬
‫تحصيل‬
‫ّ‬
‫‬
‫‬
‫العمر‬
‫‬
‫األسم‬
‫‬
‫العالقة العائلية‬
‫علمي‪/‬مهنة‬
‫تحصيل‬
‫ّ‬
‫‬
‫‬
‫العمر‬
‫‬
‫األسم‬
‫‬
‫العالقة العائلية‬
‫علمي‪/‬مهنة‬
‫تحصيل‬
‫ّ‬
‫‬
‫‬
‫العمر‬
‫‬
‫األسم‬
‫‬
‫العالقة العائلية‬
‫علمي‪/‬مهنة‬
‫تحصيل‬
‫ّ‬
‫‬
‫‬
‫العمر‬
‫‬
‫األسم‬
‫‬
‫العالقة العائلية‬
‫علمي‪/‬مهنة‬
‫تحصيل‬
‫ّ‬
‫‬
‫‬
‫العمر‬
‫‬
‫األسم‬
‫‬
‫العالقة العائلية‬
‫علمي‪/‬مهنة‬
‫تحصيل‬
‫ّ‬
‫كم سيارة تمتلك عائلتك؟‬
‫(حددي) نوع السيارة ‪ ،‬تاريخ او سنة صنعها وقيمتها بالليرة اللبنانية‪:‬‬
‫حدد‬
‫رجاء‬
‫ّ‬
‫ّ‬
‫ً‬
‫‬
‫‬
‫‪Please make sure to sign your application below; otherwise, your application will not be considered.‬‬
‫‪I certify that the information provided in this application is, to the best of my knowledge, complete and accurate. I further‬‬
‫‪understand that misrepresentations or material omissions made in this application render me morally and legally liable.‬‬
‫‪If applicant is under 18 years of age, the legal guardian is to sign together with the applicant.‬‬
‫‪13 of 18‬‬
‫ ‪Signature:‬‬
‫ ‪Date:‬‬
‫‪12 of 18‬‬
Employee Income Statement
American University of Beirut | Office of Financial Aid, Beirut, Lebanon
Form A should be completed by the employer for every earning member of the family and for each position held.
Photocopy this form as needed.
Name of applicant for financial aid: Answer all questions carefully and completely. Any missing information will jeopardize processing your application.
Form B
Detach and mail to AUB
Form A
Self-Employed Income Statement
American University of Beirut | Office of Financial Aid, Beirut, Lebanon
FORM B should be completed below and submitted with the business registration (‫ )سجل تجاري‬and income tax
statements (‫)ضريبة دخل‬. It should be completed for each self-employed member of the family.
Photocopy this form as needed.
Name of applicant: ________________________________________________________________________
Answer all questions carefully and completely. Any missing information will jeopardize processing your application.
Name of employee: Position and title: Amount in Lebanese Pounds (if none, enter ‘0’)
Self-employed is any family member providing an income to the family or contributing to the income of the
family from selling farming products, fishing products, or any other product (i.e. groceries) in a privately
owned shop.
Basic annual salary
Name of self-employed family member: Annual family allowance
Relationship to applicant: Annual transportation
Annual accommodation
Annual profits sharing amount from employer
Sole owner
Partner: Number of partners: Freelance
Other, Percent share: Specify
Annual bonus
Name of institution, if applicable: Annual commission
Registration number, if applicable: Specify any other annual benefit Date: Nature of company/owner work/business, in detail: Educational benefit (each child separately including
child name)
1.
2.
Address: 3.
/
Building
4.
5.
Number of months payable: City
/
Country
Email: Years of service: /
Street
Area
Telephone (home): Country code
/
Area code
/
Number
@
Number of employees/workers: Annual gross income in Lebanese pounds (gross income is the total revenue of the institution):
To be completed by employer
Employer’s name, title, and seal: Name of institution: Telephone: Email: Country code
/
Area code
/
Number
@
Name and seal: Type of institution, nature of work: I certify that the amounts and information above are accurate and have been verified by me.
Employer’s signature: 14 of 18
Annual net income in Lebanese pounds (net income is the total personal income of the self-employed family
member and partners, if any, after deduction of all the institution’s expenses):
Date: Signature: Date: 15 of 18
‫‪Form A‬‬
‫‪Form B‬‬
‫‪American University of Beirut | Office of Admissions, Beirut, Lebanon‬‬
‫إفادة الدخل عن عمل حر‬
‫‪Detach and mail to AUB‬‬
‫)‪University Scholarship Program (USP V‬‬
‫)‪Application for Undergraduate Study for the Academic Year (2014-15‬‬
‫)‪University Scholarship Program (USP V‬‬
‫)‪Application for Undergraduate Study for the Academic Year (2014-15‬‬
‫‪American University of Beirut | Office of Admissions, Beirut, Lebanon‬‬
‫إفادة دخل الموظف‬
‫إسم المؤسسة (بحال وجودها)‪:‬‬
‫إسم الموظف ‪ ‬‬
‫اذا لم يتوفر المبلغ الرجاء االشارة ب “ال”‬
‫الراتب الشهري األساسي‬
‫ترخيص ‪ /‬علم وخبر‪ :‬رقم‬
‫تاريخ‬
‫‬
‫التعويض العائلي‬
‫بدل مواصالت‬
‫طبيعة عمل المؤسسة ‪ /‬المالك‪( :‬بالتفصيل)‬
‫بدل سكن‬
‫المبلغ الناتج عن المشاركة بأرباح المؤسسة‬
‫‬
‫عالوة‬
‫عمولة‬
‫تعويضات أخرى‬
‫‬
‫منحة دراسية (كل ولد على حدة)‬
‫‪.١‬‬
‫‪.٢‬‬
‫‪.٣‬‬
‫‪.٤‬‬
‫‪.٥‬‬
‫عدد األشهر المدفوعة سنوي ًا ‪ ‬‬
‫العنوان والهاتف‪:‬‬
‫‬
‫عدد الموظفين ‪ /‬األجراء‪:‬‬
‫مدخول العمل اإلجمالي السنوي‪:‬‬
‫يجب ملء اإلستمارة المبينة أعاله وإرفاقها برسالة صادرة عن رب العمل تص ّرح عن المنصب الذي يشغله الموظف وتبين عدد سنوات الخدمة‪.‬‬
‫مدخول العمل الصافي السنوي‪:‬‬
‫االسم والختم‪:‬‬
‫اإلمضاء‪ :‬‬
‫إسم رب العمل‪ :‬‬
‫‬
‫التاريخ‪ :‬‬
‫ختم المؤسسة‪ :‬‬
‫مالحظة‪ :‬الرجاء إرفاق المستندات الرسمية للشركة والشركاء‪ ،‬باإلضافة إلى الميزانية وتصريح ضريبة الدخل الرسمية للسنة المنصرمة‪.‬‬
‫على كل فرد من أفراد العائلة أن يمأل الحقل المناسب في هذه اإلستمارة (أ)‪( ،‬ب)‪ ،‬أو (أ‪+‬ب)‪ .‬وفي حال العمل لدى أكثر من مؤسسة فمن‬
‫المتوجب ملء استمارتين منفصلتين‪.‬‬
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‫اإلمضاء‪ :‬‬
‫‬
‫التاريخ‪ :‬‬
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