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Ronald and Eileen Weiser Professional Development Awards

For Study and Research at the University of Michigan

2014 Application - For applicants from Armenia, Azerbaijan, Belarus, Bosnia & Herzegovina, Georgia, Russia (Kaliningrad District), Kazakhstan, Kosovo, Kyrgyzstan, Macedonia, Moldova, Serbia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan.

Please complete and submit the following application by October 15, 2013 (for travel to University of Michigan in March-April 2014 or September-November 2014). All fields are required. To save, select Print and then choose Adobe PDF. Last Name: Middle Name (if any): Age: Citizenship: City of Birth: Date of Birth: Country of Permanent Residence: Country of Birth: First Name: Gender: Male Female

Home Address (including postcode):

Preferred Phone: Preferred Email: Alternate Email: Current employer(s):

Name of Institution(s) or Organization(s)

Current position(s):

Professional Title and Department Affiliation(s)

Specialization: Current job responsibilities (continues on next page):

Current Work Address (including postcode):

Work Phone: Work Email (if different than above): Institutions, NGOs, etc., with which you have cooperated in the last three years (please specify program names, locations, and relevant dates):

English language ability (for each category below, list your ability level as fluent, very good, good, fair, or beginner): Speaking English If selected as a Weiser Professional Development Fellow, I agree to confirm my language abilities in an interview: Via telephone: Via Skype: Reading Writing Listening

List previous educational experiences in English-speaking countries (graduate or postgraduate studies, seminars, workshops, conferences, etc.), locations, and dates:

Title of research project: Brief abstract of research project:

Name of faculty partner at the University of Michigan: _______________________________ Length of desired stay: three weeks four weeks April 2014 November 2014 Second choice:

Please indicate preferred month: March 2014 September 2014 First choice: October 2014

If you have been to the U.S. on a J-1 visa within the last two years and are subject to the twoyear return residency rule, please indicate the exact dates of your last stay in the U.S.:

Please attach: 1) Your CV. 2) A copy of your doctoral diploma or highest professional degree. 3) A copy of your passport photo page. 4) A two-page personal statement describing: a) the research or collaborative project you plan to pursue at the University of Michigan, b) your reason for applying for this opportunity and how this opportunity will benefit your home institution. 5) An invitation from the University of Michigan school, department, and/or faculty partner with whom the research will be conducted; email invitation is acceptable. 6) One letter of recommendation from the rector or dean at your institution should be submitted in a sealed envelope, or sent separately to Polsko-Amerykaska Komisja Fulbrighta, ul. K.I. Gaczyskiego 4, 00-362 Warszawa, Poland. 7) If you have taken the TOEFL exam in the last three years, attach a copy of your score report. Submit by email to: