Please complete the following information

Full Name (exactly as it

appears in your passport)
Gender
Date of Birth (Format:
Month/Day/Year)
City of Birth
Country of Birth
Citizenship(s)
Country of Residency
Institution
Street address
City and Postal Code
Country
Telephone Number(s)
E-mail Address
Emergency Contact Name &
Relationship
Emergency Contact Phone
and Email

Medical, Physical, Dietary, or other Personal Considerations

Previous Travel to the United States

Circle one: Have you previously traveled to the United States? Yes /No
If so, please describe the purpose, dates, and description of any trips you
have taken to the United States. Additionally, please list any family
members or friends that reside in the United States include their city and
state (i.e., John Doe – Chicago, IL).
Education, Academic, and Professional Training
Please list all completed academic degrees beginning with the most
recent.

Degree Type Year Specialization Institution Name

graduated

Please list any other relevant training below beginning with the most
recent:

Please complete the following information on your current

position:
Title:
Position:
Institution Name, Region and Country:
Please check the box that most closely resembles your current
position:

Teacher Trainer/ Administrator

Ministry of Education Official
Senior Professor, Department Chair, Director, Editor, Officer, etc.
Associate Professor, Senior Researcher/Think-Tank Fellow, Senior
Staff, etc.
Assistant Professor, Assistant Editor, Coordinator, Mid-level Staff
Researcher/Think-Tank Fellow, etc.
Lecturer, Teacher, Consultant
Teaching Assistant, Instructor
Secondary School Teacher
Other (Please specify)

Work Experience:
Please complete the table listing your work experience from most to
least recent within the last ten years:

Start Date End Date Position Title Institution Part or Full Time

Teaching Responsibilities
Please complete the table listing the courses you are currently
teaching:

Course Title Level of Class Class U.S.

Students hours per size Studies
quarter Content
(Yes/ No)

Aside from your formal teaching duties, please describe in the space
below any assistance provided to students regarding their personal
and career goals.

Publications
Please list published articles (internet, newspaper, etc.), books, and
chapters that you have authored. Please note that all foreign titles
should be listed in English. Please list a maximum of ten
publications.
Publication Type (book, article, Year Title of Publisher
etc.) Published

Active Professional Memberships:

List any active professional memberships below:

Position Title Organization

Personal Essay
In the space below, please respond to the following prompt within the
250-word limit.

Prompt: Please explain why you are interested in participating in the

institute to which you are applying and what you expect to gain during the
six-week course. Your statement should also address how you will
leverage the experience to make a difference in your home institution, as
well as in Tunisia, by updating coursework, creating new courses,
launching new research, publishing new work, building institutional
linkages, etc.

How did you learn about this program? (Select all that apply)

U.S. Embassy website A friend/colleague who previously

participated in SUSI
U.S. Embassy Facebook Newspaper
page
Email from U.S. Embassy Internet site (please name)
University (announcement Other (please specify)
on campus)
Email from a
friend/colleague

Thank you for completing the SUSI application and we wish you luck
in the selection process!
Fill out the form and send it to TunisELprograms@state.gov