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Project Request Form for Potential Host Institutions

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I. Host Institution Information

Public and private higher education institutions in Ghana, Nigeria, Kenya, Tanzania, South Africa and Uganda that are accredited by the applicable national agency in their country are eligible to submit a pro ect re!uest to host a "ello#, an African$born scholar #ho lives and #or%s in a college or university in the United States or &anada'

1. Name of Host Institution

2. Department Facult! Institute

". #treet $ddress

%. Cit!

&. Postal Code

'. #tate or Pro(ince )if applica*le+

,. Countr!

-. Contact Person Name )include prefi./ e.g. Dr./ 0r./ 0s./ etc.+

1. Contact Person $cademic 2itle

13. Contact Person 2elep4one

11. Contact Person Fa.

12. Contact Person 5mail

1". Contact Person $lternate 5mail

1%. 6e*site

II. Project Description

Pro ects may be in any academic discipline' (ligible activities for the &arnegie African )iaspora "ello#ship Program are* research collaboration curriculum co$development and+or graduate student training and mentoring

1. Discipline Requested

2. #u*fields or #peciali7ations Requested

". 8t4er Fields of Interest or 5.pertise Requested )if t4is is an interdisciplinar! request+

%. Project $cti(ities
Describe the proposed activities and how the Fellow would be involved. )9imit: &33 ;ords+

&. Project 8*jecti(es

Please address why the project is needed, and how the project will address these needs. )9imit: &33 ;ords+

'. Project Impact
Please comment on the expected outcomes in both the immediate and long-term (within five years for the project,

including impact and outcomes for the host institution, the fellow and the fellow!s home institution.
Please also comment on how your institution will evaluate and measure the project!s impact. )9imit: &33 ;ords+

III. Timeframe
(ligible pro ects #ill involve a visit of bet#een t#o #ee%s and one semester by the "ello# to your institution' The pro ect visit may begin as early as ,une -./0' Scholars and their institutions in the United States, &anada and Africa #ho participate in the program are encouraged to find #ays to continue collaborations'

1. Proposed $rri(al Date )Da! 0ont4 <ear+

2. 9engt4 of =isit )minimum of 1% da!s/ ma.imum of 1&3 da!s+

". Future Planned Colla*orations/ If $n!

IV. Cost Share Commitment

African institutions are encouraged to provide cost$share for hosting a "ello#, including lodging, meals and local transport 1to+from airport, as #ell as to+from campus from site of lodging2 for the "ello#' 3nstitutions may offer in$%ind support in lieu of direct payment to the "ello#' 4hen the pro ect re!uest is submitted, a letter of support from an administrator at the level of )ean or higher needs to be attached confirming the cost$share plans' 3n addition, please describe proposed cost share plans belo#'

1. Contact Name for all Cost>#4are $rrangements

2. $cademic 2itle

". 2elep4one

%. 5mail $ddress

&. 9odging $rrangements )9imit 233 ;ords+

'. 5stimated ?.#. Dollar $mount for 9odging

,. In>Countr! 2ra(el $rrangements )9imit 233 ;ords+

-. 5stimated ?.#. Dollar $mount of In>Countr! 2ra(el

1. 0eal $rrangements )9imit 233 ;ords+

13. 5stimated ?.#. Dollar $mount for 0eals

11. Name and 2itle of $dministrator Pro(iding 9etter of #upport "he administrator supporting this project should hold the position of dean or higher at the host institution. "he letter of support should be signed by the administrator and be on university letterhead. "he letter will be submitted separately through the online project re#uest system.

V. Prospective Fellow of Interest

3nstitutions are #elcome, but not re!uired, to develop a pro ect in collaboration #ith a prospective "ello#, an African$born scholar #ho lives and #or%s in a college or university in the United States or &anada' If your institution has not i entifie a specific can i ate for the project! you may leave this section "lan#. Can i ates apply via a separate form to e$press interest in participatin% in this pro%ram. II& will search a roster of can i ates! to fin one or more possi"le matches! accor in% to the iscipline! speciali'ations! e$pertise! activities an o"jectives escri"e in the project re(uest.

1. Candidate of Interest Name )include prefi./ e.g. Dr./ 0r. 0s./ etc.+

2. $cademic 2itle

". Home Institution Name

%. #c4ool Department Name

&. Institution Cit!

'. Institution ?.#. #tate or Canadian Pro(ince

,. Institution Postal Code

-. Candidate 2elep4one

1. 5mail

13. $lternate 5mail

11 Pro(ide @ustification for Requesting Candidate)s+ )9imit 233 ;ords+

12. Please descri*e an! pre(ious ;orAing relations4ip or colla*oration ;it4 t4e sc4olar)s+ or sc4olar

institution)s+ )9imit &33 ;ords+