C. REASONS for SEEKING an EXTENSION (Please Answer Either Question 1 Or 2)

To request an extension of your program in order to complete a Professional Affiliation beyond the prescribed course of study, please complete and submit this form with the other documentation required for the extension request.

Fellow’s Name: Host University: -Please Select One-American UniversityArizona State UniversityBoston UniversityUniversity of California, DavisCornell UniversityEmory UniversityJohns Hopkins UniversityUniversity of Maryland, College ParkUniversity of Minnesota- Humphrey InstituteUniversity of Minnesota- Law SchoolMassachusetts Institute of TechnologyMichigan State UniversityPennsylvania State UniversitySyracuse UniversityTulane UniversityUniversity of WashingtonVanderbilt UniversityVirginia Commonwealth University

A. DATES OF EXTENSION: From: 6/14/2013 To: (this date must be confirmed in writing by your Professional Affiliation host on the Confirmation of Offer of Professional Affiliation form)

B. NUMBER OF HOURS PER WEEK: (must be at least 35 hours/week)

C. REASONS FOR SEEKING AN EXTENSION (Please answer either question 1 or 2):

1. If you are seeking an extension of your current Professional Affiliation, please give a detailed description of your reasons for requesting an extension. Please state the goals and objectives of the Professional Affiliation and how it relates to your major field of study. Please also describe how this opportunity will benefit you when you return to your home country.

2. If you are seeking an extension to begin a new Professional Affiliation, please state the goals and objectives of the Professional Affiliation and how it relates to your major field of study. Please also describe why this new opportunity will be valuable to your professional development and to your work when you return to your home country.

• By my signature below, I confirm that I am aware of the two-year home residency requirement and that I am committed to returning to my home country at the conclusion of my extension period.

Signature of Fellow: ______Date: ______

• I have reviewed the Extension Request proposal and confirm that the proposed activity is valuable to the Fellow’s professional development.

Signature of University Coordinator: ______Date: ______

• Approved by IIE Alternate Responsible Officer

Signature: ______Date: ______

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