Questionnaire for the English-Speaking Union (Argentina)
Questionnaire for The English-Speaking Union (Argentina)
Walter Hines Page Scholarships
Name of Grantee:______
Home Address: ______
Work Address: ______
Telephone Number – Home: ______Work: ______
Fax Number: ______E-mail:
Age and Marital Status: ____
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1. STATE THE OBJECTIVE OF YOUR U.S. TOUR: Please be as specific as possible as your professional appointments will be arranged using this information contained in this statement.
2. PRESENT POSITION:
3. DESCRIPTION OF YOUR POSITION, SCHOOL, AND COMMUNITY: (Age of students, independent or state, single sex or co-educational, day or boarding, urban or rural, town population, particular or outstanding characteristics of your school and students, etc.) Use the reverse side of this page, if necessary.
4. PAST PROFESSIONAL EXPERIENCE: (List most recent position first, your title, name of affiliation, dates, and a brief description of your position.)
5. EDUCATIONAL BACKGROUND: (List most recent first, name of schools, field of study, years attended, secondary-post graduate.)
6. LIST THE PLACES YOU WOULD LIKE TO VISIT IN THE U.S. AND WHY (5-10 PLACES): Indicate any particular institutions you would like to visit so that the ESU may attempt to make an appointment for you where requested. If necessary, you may attach an extra sheet.
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7. GIVE THE NAMES AND ADDRESSES OF ANY PERSONAL FRIENDS OR RELATIVES IN THE U.S. WITH WHOM YOU WISH TO STAY DURING ANY PART OF YOUR TRAVEL:
8. GIVE THE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ANY SPECIFIC PROFESSIONAL PERSONS YOU WOULD LIKE TO MEET WITH DURING ANY PART OF YOUR TRAVEL:
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9. WHAT TYPE OF PROFESSIONAL PERSONS WOULD YOU MOST LIKE TO MEET? (Professors, school teachers, government representatives, organizational leaders, etc.):
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10.PROFESSIONAL INTERESTS (LIST): This list will be used as a reference for arranging appointments for you in case individuals are not available to meet with you regarding your main objective.
11.PERSONAL INTERESTS AND HOBBIES: This list will be used to match you with your hosts and arrange your dinner engagements as well as plan weekend activities.
12.ARE YOU WILLING TO SPEAK TO MEMBERS OF THE ESU BRANCHES YOU VISIT OR TO GROUPS AT SCHOOLS, UNIVERSITIES, ETC? (List the subjects on which you could speak, the kinds of groups you prefer to address and whether or not you have any visual aids such as slides, videos, etc.)
13.Is it your intention to stay in the USA at your own expense before the start of or after the completion of your tour? If so, please indicate the amount of time you might wish to spend.
14.GRANTEE COMMENTS: Please write one or two brief paragraphs, on the reverse side of this page, giving your reasons for seeking this scholarship to travel in the U.S., what you expect to accomplish as related to your professional and personal interests, what you hope to achieve in terms of visiting your host communities, and what you may be able to share with them. (This statement will be verbatim in the biographical notes so be brief and concise.)