Study of the United States Institutes (SUSI)

U.S. Department of State

Study of the United States Institutes (SUSI)

Application Form for Secondary Educator and Scholar Programs

U.S. Embassy in Nepal

A. Title of Institute (mark only one)

____ Secondary School Educators

____ American Politics and Political Thought

____ Contemporary American Literature

____ Journalism and Media

____ Religious Pluralism in the United States

____ U.S. Culture and Society

____ U.S. Foreign Policy

B. Full Name (exactly as it appears on passport)

Prefix (Mr/Mrs/Dr):

Surname:

First Name:

Middle Name:

C. Gender ____ Male ____ Female

D. Date of Birth (Month/Day/Year):

E. Birth City:

F. Birth Country:

G. Citizenship (list all passports held):

H. Residency:

I. Medical, Physical, Dietary or other Personal Considerations (Please describe any pre-existing medical conditions, including any prescription medication the candidate may be taking, allergies, or other dietary or personal consideration. This will not affect candidate selection, but will enable the host institution to make any necessary accommodations.):

J. Contact Information

Address:

City:

Home State or Province:

Postal Code:

Country :

Email:

Phone:

K. Current Position

Title:

Institution Name:

Institution Country:

L. Work Experience

Include previous positions with title, institution name, date started/ended, and country (can be substituted by a CV if all required information is contained).

M. Education, Academic and Professional Training

Please list all earned degrees beginning with most recent, including degree earned, year earned, specialization, and institution (can be substituted by a CV if all required information is contained).

Additional Professional Training:

N. Active Professional Memberships

Active Professional Memberships independent of current professional responsibilities. These should not include university committee work or other professional duties directly related to current employment. Include position, title, and organization.

O. Publications Related to the Institute Theme (up to 10)

Please list all foreign titles in English. Include publication type, year, and publisher (can be substituted by a CV if all required information is contained).

P. Previous Experience in the United States

Include purpose, dates started/ended, and description of experience.

Q. Family/Close Friends Residing in the United States

Please include name, city, and state.

R. Evidence of English Fluency

List all English exams with scores, academic degrees, and significant experience that demonstrates your ability to communicate in English.

S. Professional Responsibilities

Please discuss your professional responsibilities in greater detail, including research interests, administrative responsibilities (ex. curriculum design), and/or other pertinent information.

Current Courses Taught:

Include course title, level of students, classroom hours per semester, number of students, nad percentage of course that covers U.S. studies content.

Current Student Advising:

Advising is not the same as teaching. List the number of students, their level, and hours spent providing assistance in helping students clarifying personal and career goals, and evaluating progress towards those goals. This section can also include supervision of PhD and graduate students.

What are the likely potential outcomes of attending this program (select all that reasonably apply)?

____ Update Existing Course ____ New Publication

____ Create New Course ____ Professional Promotion

____ Create New Degree Program ____ New Research Project

____ University Curriculum Redesign ____ New Professional Organization

____ National Curriculum Redesign ____ New Institutional Linkages

____ Government or Ministry Policy ____ Raise Institutional Profile

T. Personal Essay (limit 4,500 characters)

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 Institute would help you achieve the "Other Potential Outcomes" you have checked above.