STUDY OF THE UNITED STATES INSTITUTES FOR SCHOLARS

& FOREIGN SCHOOL EDUCATORS

SUMMER OF 2015
******

APPLICATION
TITLE OF THE INSTITUTE YOU ARE APPLYING FOR
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NAME (as it appears on passport):
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DATE OF BIRTH: (Month, Day, Year)
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CITY OF BIRTH: ________________________________________________________

COUNTRY OF BIRTH: ________________________________________________

COUNTRY OF RESIDENCE: ___ __________________________________________

COUNTRY OF CITIZENSHIP: _ ____________________________________________

HOME ADDRESS: ______________________________________________________

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HOME TELEPHONE: ___________________________________________________

CELL PHONE: __________________________________________________________

E-MAIL ADDRESS: ______________________________________________________

GENDER: _____________________________________________________________
MEDICAL, PHYSICAL, DIETARY OR OTHER PERSONAL CONSIDERATIONS (No
physical examination is required to participate in this program):
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CURRENT POSITION AND TITLE:

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CURRENT INSTITUTIONAL AFFILIATION AND COMPLETTE ADDRESS:

______________________________________________________________________
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WORK EXPERIENCE, INCLUDING PREVIOUS POSITIONS AND TITLES:

___________________________________________________________________
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EDUCATION, ACADEMIC AND PROFESSIONAL TRAINING INCLUDING

DEGREES EARNED AND FIELD OF SPECIALIZATION:
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ACTIVE PROFESSIONAL MEMBERSHIPS:

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SHORT LIST OF RELEVANT PUBLICATIONS: (Please choose no more than five to

ten of your most important publications).
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PREVIOUS EXPERIENCE IN THE UNITED STATES: (Please list all trips you have
made to the United States and include approximate dates and reason for travel).
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FAMILY RESIDING IN THE UNITED SATES:

(Please list any immediate family members who are currently residing in the United
States, including city and state.
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EVIDENCE OF ENGLISH FLUENCY:

(Please list any English test scores you have received, if you have taken any English
exams in the last three years).
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PLEASE DESCRIBE THE EXTENT OF CURRENT OR PROJECTED U.S. STUDIES

COURSE CONTENT AND MATERIALS BEING TAUGHT OR DEVELOPED AT

YOUR INSTITUTIONS:
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LIKELY RELEVANCE OF THE PROGRAM TO YOUR PROFESSIONAL

RESPONSIBILITIES:
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THE POTENTIAL IMPACT OF YOUR PARTICIPATION ON THE DEVELOPMENT

OF THE STUDY OF THE U.S. AT YOUR INSTITUTION:
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________________________________________________________________________
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SHORT PERSONAL STATEMENT:

Tell us about yourself and your goals including the following: How do your background
and/or interests make you competitive for this particular institute? What will you
contribute to your academic institute? How do you expect this experience will affect your
future professional career? How will it affect you personally? Please structure your essay
in paragraphs and limit your response to 250 words, or approximately half a page, single
spaced.