Nomination Form – FY-14 Study of the United States Institutes Scholars

A. Nominee's Full Name (exactly as it appears on his/herpassport. Clearly identify what the nominee's first,middle and surnames are as they appear on his/herPassport):

Prefix:

Last Name:

First Name:

Middle Name:

B. Gender

C. Date of Birth (please spell out Month, Day, Year):

D. Birth City:

E. Birth Country:

F. Residency:

G. Citizenship:

H:Medical, Physical, Dietary or other PersonalConsiderations: Please state whether the candidate hasany existing medical conditions or currently is takingany prescription medication. This will not affectcandidate selection, but will enable the host institutionto make any necessary accommodations:

I. Contact information:

  • Address:
  • City:
  • Home State or Province:
  • Home Country Name:
  • Residence No:
  • Mobile No:
  • Email:

J. Current Position and Title

Position Type (Choose one from the list below):

  • Senior University Official (President, Provost), Government Minister, Senior Executive, etc
  • University Dean, Government Advisor, Vice President, Junior Executive
  • 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
  • Other (please explain):

Title:

Institution Name:

Institution Country:

K. Work Experience, including previous positions andTitles:

From / To / Title/Institution / Part/full time position

M. Education, Academic and Professional Training,Including degree earned and fields of specialization

Degree Earned / Year Earned / Specialization/ Institution

Additional Professional Training:

N. Active Professional Memberships

Position / Title / Organization

O. Publications (please do not list any more than 10)

Publication Type / Year / Title Publisher

P. Previous Experience in the United States: Please list any and all trips the candidate has made to the United States and include approximate dates and the reason for travel.

Purpose / From / To / Description

Q. Family Residing in the United States: Please list any immediate family members who are currently residing in the United States, including city and state.

R. Evidence of English Fluency (e.g. personal interview,test score, etc.)

S. Professional Responsibilities:

Current Courses Taught:

Course Title / Level of Students / Classroom Hours Per Semester / # of Students / U.S. Studies content (%)

Current Student Advising:

Advising is not the same as teaching. We are looking for the number of students, their level, and hours the nominee spends providing assistance in helping students clarifying personal and career goals, and evaluating progress towards those goals. This section can also include those that supervise PhD and graduate students.

Number of Students Advised Studying U.S. Related Topics / Level of Students / Hours of Advising Per Student

Other Potential Outcomes:

Please select any likely potential professional outcomes of the program:

  • Update Existing Course
  • Create New Course
  • Create New Degree Program
  • University Curriculum Redesign
  • National Curriculum Redesign
  • New Research Project
  • New Publication
  • Professional Promotion
  • Government or Ministry Policy
  • New Professional Organization
  • New Institutional Linkages
  • Raise Institutional Profile

T. Personal Statement (Limit 4, 500 characters each)

  1. Please discuss how your participation would enhance your personal and professional goals, the current state of U.S. studies in your home country, or upon the institute. Include how attending this institution would help you achieve the “Other Potential Outcomes” you have checked above.

For official use only

U. Statement by Commission/post justifying participationof nominee in the institute:(Limit 250 words each)

  1. Please discuss why this candidate has been nominated above all other candidates, and how this candidate’s participation fits into the post’s current efforts to promote a greater understanding of the United States.
  1. Please discuss how the nominee’s participation is relevant to the Post’s Mission Goals, and what sort of collaboration the Post anticipates having with either the nominee or his/her institution in the future.

U. Post/Commission Action Officer (the person whomECA/A/E/USS should contact with all inquiries about thenomination): Name, Complete Mailing Address, E-mail,Telephone, Fax

Name:

Address:

Email:

Phone:

Fax: