PRELIMINARY APPLICATION FOR FULBRIGHT AWARDFOR

2016FULBRIGHT-TRF JUNIOR RESEARCH SCHOLARSHIP PROGRAM

______

Complete this form in English except where otherwise indicated. Submit the completed application along with your proposal and required supporting documents to Fulbright Thailand within the application deadline.

1. Name:

Mr.

Mrs.

Miss (underline family name) (Thai)

Please indicate your status:__ _ TRF’sRoyal Golden Jubilee’s doctoralstudent

_____General doctoral student

Proposed project title:

Proposed U.S. Host Affiliation:

Grant period(not before Sep. 1, 2016 and no later than Feb.28, 2017):

2. Mailing Address:

a: Home: (English)

(Thai)

Mobile:

b: Office's name and address: (English)

Tel: Fax: E-mail:

3. Age: Birth date: Citizenship:

4. Single Married Name of spouse:

Spouse's occupation and address:

5. Are you a government official? (please circle)Yes No

If yes, give date of permanent employment:

Do you expect to be granted leave of absence from your present position if you are awarded a grant? (please circle) Yes No

6. Total years of working experience (excluding periods of study)

7. English Test (please circle): TOEFL iBT, ITP TOEFL, CU-TEP Score:

8. Educational institutions attended WITH THE MOST RECENT:

INSTITUTION / FIELD OF SPECIALIZATION / YEARS ATTENDED / CERTIFICATE/DIPLOMA OR DEGREE RECEIVED

9. Professional teaching / lecturing / research experience WITH THE MOST RECENT:

POSITION / INSTITUTION/EMPLOYER / SUBJECT TAUGHT / TOPICS / FIELDS / DATE/YEARS

10. Other professional or practical experience WITH THE MOST RECENT:

TITLE OF POSITION / INSTITUTION / TYPE OF WORK / DATE/YEARS

11. Research and Publications:

TITLE / SPONSORED / FUNDED BY / DATE/YEARS

12. Give the names and positions of two references:

a.

(Name)(Position)(Present Institution)

b.

(Name)(Position)(Present Institution)

13. In what subject areas do you feel you are best qualified to conduct research?

14. Do you expect to be granted a leave of absence from your present position in the event that you are awarded a grant? (please circle)Yes No

15. Have you ever taught or given lectures in English to English speaking people? (If yes, give dates and place)

16. While in the United States, would you be willing and able to lecture and speak informally to various private audiences, such as Women's Clubs, Faculty Clubs, Rotary Clubs, groups interested inThailand and Asia, etc.?

17. Describe in detail your research, lecturing or project proposal, the rationale, procedures to be used, and anticipated length of time required to complete the work. (Detailed research proposalnot exceeding 5 pages typed, please describe in separated sheets)

18. Please write a biographic essay, including information about your important academic and professional background, research you have undertaken (other than that required for a Ph.D. degree), previous achievements and other writing you have done for publications. Also mention international conferences, seminars, etc., in which you have participated. (Please describe in separated sheets)

Signature of applicant:

Date:

Checklist of documents enclosed:

1 original application form (with a photo attached)

Detailed research proposal (not exceeding 5 pages typed, font no.10-12 Ariel or Tahoma, preferably)

Biographic essay (not exceeding 2 pages typed,font no.10-12 Ariel or Tahoma, preferably)

Resume/CV

A copy of transcripts (Master’s and PhD’s)

A copyofvalid Englishlanguage official score report(TOEFL iBT or ITP or CU-TEP)

An official letter of invitation from the U.S. institution (a copy of a PDF file is acceptable)

Two letters of recommendation (sealed in envelopes)

Make 4 additional copies (except Recommendation Letters)from the original in

a total of 5 sets of complete applications (each set MUST comprise no. 1-7 in order)

Please do not staple any of your applications

Your documents must be in English only

Rev. 06/2015

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