2014 Study of the United States Institutes for Faculty and Scholars

APPLICATION FO!
A. Title of the U.S. Studies Institute you are applying to
B. Candidates Full Name, exatly as it appears on passport
Prefix: Dr. Miss Mr. Mrs. Ms. Prof.
Last Name:
First Name:
Middle Name:
C. !ender
Male
Female
". "ate of Birth (mm/dd/yyyy):
#. Birth City$
F. Birth Country$
!. Citi%enship
Primary:
Secondary: (if applicable)
&. Country of 'esideny$
I. (edial, )hysial, "ietary or other )ersonal Considerations
Disability:
Blind and is!al "mpairments P#ysical Disabilities
Deaf and $earin% "mpairments Psyc#iatric Disabilities
Learnin% Disabilities
Please describe any pre&existin% medical conditions' incl!din% any prescription medication yo!
may be ta(in%' or ot#er dietary or personal consideration.
)#is *ill not affect t#e candidate+s selection' b!t *ill enable t#e #ost instit!tion to ma(e any
necessary accommodations.
*. Candidate Contat Information
,ddress:
-ity:
$ome State or Pro.ince:
Postal -ode:
$ome -o!ntry Name:
/mail:
P#one (incl!de area code):
-ell (incl!de area code):
-ontact name 0 relations#ip:
/mer%ency -ontact P#one:
/mer%ency -ontact /mail:
+. Current )osition, Title, Institution
Position )ype:
Senior 1ni.ersity 2fficial (President' Pro.ost)' 3o.ernment Minister' Senior /xec!ti.e' etc.
1ni.ersity Dean' 3o.ernment ,d.isor' ice President' 4!nior /xec!ti.e'
Senior Professor' Department -#air' Director' /ditor' 2fficer' etc.
,ssociate Professor' Senior 5esearc#er/)#in(&)an( Fello*' Senior Staff' etc.
,ssistant Professor' ,ssistant /ditor' -oordinator' mid&le.el Staff researc#er/)#in(&)an(
fello*' etc.
Lect!rer' )eac#er' -ons!ltant
)eac#in% ,ssistant' "nstr!ctor
2t#er
)itle:
"nstit!tion Name:
"nstit!tion -o!ntry:
,ddress:
P#one (incl!de area code):
,. -or. experiene, inluding pre/ious positions and titles$
From: )o: )itle/"nstit!tion (Please specify if position is part&time
(. #duation, Aademi and )rofessional Training$
Please list all earned de%rees be%innin% *it# most recent. De%rees listed s#o!ld reflect t#e closest
1.S. e6!i.alent.
De%ree /arned: 7ear earned:
(Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree)
Speciali:ation/"nstit!tion:
De%ree /arned: 7ear earned:
(Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree)
Speciali:ation:
De%ree /arned: 7ear earned:
(Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree)
Speciali:ation:
De%ree /arned: 7ear earned:
(Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree)
Speciali:ation:
De%ree /arned: 7ear earned:
(Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree)
Speciali:ation:
Additional )rofessional Training$
N. Ati/e )rofessional (em0erships$
,cti.e Professional Members#ips independent of c!rrent professional responsibilities. )#ese
s#o!ld not incl!de !ni.ersity committee *or( or ot#er professional d!ties directly related to
c!rrent employment.
Position )itle 2r%ani:ation
1. )u0liations 'elated to the Institute Theme 2up to 345
Please list all forei%n titles in /n%lis#' incl!din% *#et#er boo(' c#apter' ;o!rnal article' ne*spaper
article' *eb article' etc.
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)
P!blication )itle/P!blis#er:
). )re/ious #xperiene in the United States
P!rpose of .isit:
From: )o: (mm/dd/yyyy)
Description:
P!rpose of .isit:
From: )o: (mm/dd/yyyy)
Description:
P!rpose of .isit:
From: )o: (mm/dd/yyyy)
Description:
6. Family7Friends 'esiding in the United States$
Please incl!de city and state (/xample: 4o#n Doe = -#ica%o' "L)
'. #/idene of #nglish Flueny$
Preferably an "B )2/FL or "nstit!tional )2/FL score. "n t#e e.ent /n%lis# score is not a.ailable'
applicants s#o!ld complete t#e attac#ed /n%lis# proficiency e.al!ation form.
S. )rofessional 'esponsi0ilities$
Please disc!ss yo!r professional responsibilities in %reater detail' incl!din% researc# interests'
administrati.e responsibilities (ex. -!rric!l!m desi%n)' and/or ot#er pertinent information.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Current Courses Taught$
-o!rse title:
Le.el of st!dents (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool):
-lassroom #o!rs per semester:
N!mber of st!dents:
/stimated percent of 1.S. St!dies content:
-o!rse title:
Le.el of st!dents (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool):
-lassroom #o!rs per semester:
N!mber of st!dents:
/stimated percent of 1.S. St!dies content:
-o!rse title:
Le.el of st!dent (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool):
-lassroom #o!rs per semester:
N!mber of st!dents:
/stimated percent of 1.S. St!dies content:
Please copy format as needed for additional co!rses:
8888888888888888888888888888888888888888888888888888888888888888888888
Current Student Ad/ising$
,d.isin% is not t#e same as teac#in%. <e are loo(in% for t#e n!mber of st!dents' t#eir le.el' and
#o!rs t#e nominee spends pro.idin% assistance in #elpin% st!dents clarifyin% personal and career
%oals' and e.al!atin% pro%ress to*ards t#ose %oals. )#is section can also incl!de t#ose t#at
s!per.ise P#D and %rad!ate st!dents.
N!mber of st!dents ad.ised *#o are st!dyin% 1.S. related topics:
Le.el of st!dent (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool):
N!mber of ad.isin% #o!rs:
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
1ther )otential 1utomes$
Please select any li(ely potential professional o!tcomes of t#is pro%ram.
1pdate existin% co!rse -reate ne* co!rse
-reate ne* de%ree pro%ram 1ni.ersity c!rric!l!m redesi%n
National c!rric!l!m redesi%n Ne* researc# pro;ect
Ne* p!blication Professional promotion
3o.ernment or Ministry Policy Ne* professional or%ani:ation
Ne* instit!tional lin(a%es 5aise instit!tional profile
T. )ersonal #ssay
Limit 9?@ *ords.
A) Please disc!ss #o* yo!r participation *o!ld en#ance yo!r personal and professional %oals' t#e
c!rrent state of 1.S. St!dies in yo!r #ome co!ntry' or !pon t#e "nstit!te. "ncl!de #o* attendin%
t#is "nstit!te *o!ld #elp yo! ac#ie.e t#e B2t#er Potential 2!tcomesC yo! #a.e c#ec(ed abo.e.
Please enclose the following:

- Your full CV in English, if readily available if not, in Spanish.
- support letter fro! your i!!ediate supervisor endorsing your candidacy and confir!ing your
availability to travel if selected as well as the "epart!ent#s or institution#s interest in developing or
enhancing $.S. Studies. %he letter !ay be written in Spanish and should be addressed to:
&s. Stephanie Sypta'-(a!nath
Cultural ffairs )fficer
$.S. E!bassy
&e*ico, ". +.
Please sub!it your application for! and acco!panying docu!ents as an E!ail attach!ent to:
solicitudesbecas,state.gov. %he sub-ect of the e-!ail should be your first na!e, last na!e and the
.nstitute you are applying to. E*a!ple: &argarita /on01le0 2 3456 S$S. $.S. Culture and Society
"E"7.8E: 9anuary 5:, 3456
+or further infor!ation on the .nstitutes please contact:
Citlali &ill1n
Cultural ffairs )ffice
Public ffairs Section
$.S. E!bassy &e*ico
E!ail: !illangc,state.gov