Public Affairs Office
U.S. Embassy Mongolia

2017-2018 HUBERT HUMPHREY FELLOWSHIP

APPLICATION FORM

Note for Applicants: All the information stated in this application (including your essay) must be true and your own work. Any misrepresentation of information or documents (including English test score, references and diploma) as well as plagiarism will be grounds for immediate disqualification from consideration at any stage of the selection and nomination.

1. FIRST AND LAST NAME: ______

2. YEAR AND PLACE OF BIRTH: ______

______

3. CONTACT INFORMATION:

Telephone: ______E-Mail: ______

Home Address: ______

4. PRESENT POSITION TITLE: ______

Institution: ______

Work Address: ______

5. PREVIOUS POSITIONS (attach separate sheets if necessary):

Title: ______

Institution: ______

Date (mm/yyyy-mm/yyyy): ______

Title: ______

Institution: ______

Date (mm/yyyy-mm/yyyy): ______

6. EDUCATION (If necessary, you may continue this section on a separate sheet of paper):

A. Name/Type of Degree Received:______

Year: _____ Institution: ______

B. Name/Type of Degree Received:______

Year: _____ Institution: ______

C. Name/Type of Degree Received:______

Year: _____ Institution: ______

8. DIPLOMA AND TRANSCRIPT: Attach a copy of your Bachelor’s diploma and transcripts (If in Mongolian, please provide certified English translation).

9. ENGLISH LANGUAGE ABILITY: Please attach a copy of your official IBT, PBT or IELTS score report. We won’t accept unofficial scores such as screen shots of test results.

10. PREVIOUS U.S. EXPERIENCE: Please indicate here any prior U.S. experience of more than 3 weeks (include dates, purpose and duration). If you have ever participated in a U.S. Government scholarship program before, please also indicate that here: ______

11. FIELD OF STUDY: From the Humphrey fields of studies, please indicate here which field of study you wish to pursue (see fields listed on the announcement):

______

12. REFERENCES: Please attach letters of recommendation from two people who can attest to your academic and professional abilities. Reference letters should have the full name, title and contact information of the reference provider and should be signed by the reference provider. Letters of reference must be provided in English only. If the letter is in Mongolian, please provide a certified translation. The letters of reference shouldn’t be emailed or mailed to the embassy separately.

13. ESSAY: Please attach a typed, concise (no more than two pages long) essay, in English, explaining why you wish to study in the United States, and what you would like to do after completing that study.

14. EMBASSY AFFILIATIONS: Please state if any of your family members or close relatives work at the U.S. Embassy. If so, please provide their full name and position.

15. Please check below for which Humphrey program you are applying to:

□ Regular Humphrey (IBT 71, PBT 525) □ LTE Humphrey (IBT 41-62, PBT 440-500)

APPLICATION CHECK LIST: A complete application will include:

A.  2017-2018 Hubert Humphrey Application Form;

B.  A certified English copy of your diploma and transcripts;

C.  English language score (IBT, TOEFL, or IELTS);

D.  Essay;

E.  Two references.

*Please do not staple any part of your application and affiliated supplemental documents.
*Application and essay must be typed. Hand-written applications will be technically disqualified.
*Please be sure to follow all instructions.

Completed applications must be submitted to Public Affairs Section of the U.S. Embassy on May 23, 2016 at noon 12:00p.m.:

U.S. Embassy
Denver Street #3, 11th Micro-District
Ulaanbaatar 14190, Mongolia

Please put the entire application materials in one envelope and clearly mark with your full name and put “Application for Humphrey Program”. Please leave the application with the guards at the U.S. Embassy (see address above) on work days during work hours (Monday-Friday, 8:30a.m.-5:00p.m.). We wish you the best of success with your application!

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