A.TitleofInstitute

Select

STUDYOFTHEU.S.INSTITUTES(SUSI)SCHOLARNOMINATIONFORM

B.Nominee'sFullName,ExactlyAsItAppearsonNominee'sPassport

Prefix:Select...

LastName:FirstName:MiddleName:

  1. GenderMale

Female

D.DateofBirth

Typemm­dd­yyyyandclick on calendar menutoconfirm Month,Day, andYear.

E.CityofBirth

  1. CountryofBirth
  1. CitizenshipPrimary:

Secondary:(if applicable)

H.Residency

  1. Medical,Physical,DietaryorOtherPersonalConsiderations

Disability:…………………………………………………………..

Pleasedescribeany pre­existingmedical conditions,including any prescriptionmedicationnomineemay be taking, orany otherdietaryorpersonalconsideration.

Thiswillnotaffectthenominee'sselection,butwillenablethehost institutiontomakeanynecessaryaccommodations.

J.Nominee'sContactInformation

Address:

(NoP.O. BOX)

City:HomeStateorProvince:

if applicable

PostalCode:

if applicable

HomeCountryName:

Email:*Required

Phone:Numbers only. Forexample:

123456789

EmergencyContactNameRelationship:

Example: John Doe,Husband

EmergencyContactPhone:Numbersonly

EmergencyContactEmail:

  1. CurrentPosition,Title,Institution

PositionType:Senior UniversityOfficial (President, Provost), Government Minister,Senior Executive,etc.

UniversityDean,Government Advisor, Vice President,Junior Executive

Senior Professor, DepartmentChair,Director,Editor, Officer, etc.

AssociateProfessor,SeniorResearcher/Think­Tank Fellow,SeniorStaff, etc.

Title:InstitutionName:InstitutionCountry:

AssistantProfessor,Assistant Editor,Coordinator, mid­levelStaffResearcher/Think­Tankfellow,etc.

Lecturer,Teacher, ConsultantTeaching Assistant,InstructorOther

L.WorkExperience,IncludingPreviousPositionsandTitles

From: / To: / Title/Institution(Pleasespecify if position ispart­time)
  1. Education,AcademicandProfessionalTraining:

Pleaselistallearneddegreesbeginningwithmostrecent.DegreeslistedshouldreflecttheclosestU.S.equivalent.

DegreeEarned / Year Earned / Specialization/Institution

AdditionalProfessionalTraining:

  1. ActiveProfessionalMemberships:

ActiveProfessionalMembershipsindependentofcurrentprofessionalresponsibilities.Theseshouldnotincludeuniversitycommitteeworkorotherprofessionaldutiesdirectlyrelatedtocurrentemployment.

Position / Title / Organization
  1. PublicationsRelatedtotheInstituteTheme(upto10)

Please listall foreigntitles inEnglish, including whetherbook, chapter, journal article, newspaperarticle, web article, etc.

Publication Type / Year / Title Publisher

P.HastheNomineeTravelledtotheU.S.Before:Select...

Ifyes,pleasespecifybelow.

Purpose / From / To / Description
  1. Family/FriendsResidingintheUnitedStates...

*Pleaseincludecityandstate (Example:John Doe ­Chicago, IL)

ifyes,pleasespecifybelow

  1. EvidenceofEnglishFluency(Pleasecommentonthenominee'slevelofEnglish)

S.ProfessionalResponsibilities

Nomineeshoulddiscussprofessionalresponsibilitiesingreaterdetail,includingresearchinterests,administrativeresponsibilities(ex.curriculumdesign), and/or otherpertinentinformation.

CurrentCoursesTaught:

Course Title / LevelofStudents / ClassroomHoursPerSemester / # Students / U.S.StudiesContent(%)

CurrentStudentAdvising:

Advisingis not the sameasteaching. We arelookingforthenumberofstudents, theirlevel, and hours the

nomineespends providingassistance in helpingstudentsclarifyingpersonaland careergoals,and evaluating progresstowardsthosegoals.Thissection canalsoincludethosethatsupervisePhDand graduatestudents.

Numberof StudentsAdvisedStudyingU.S.RelatedTopics / Level of Students / Hours of AdvisingPerStudentPer Year

OtherPotentialOutcomes:

Pleaseselectanylikelypotentialprofessionaloutcomesofthisprogram.

UpdateExisting Course
UniversityCurriculum Redesign / CreateNew Course
National Curriculum Redesign / Create NewDegreeProgram
NewResearch Project
New Publication
New ProfessionalOrganization / ProfessionalPromotionNew InstitutionalLinkages / Government or MinistryPolicyRaise InstitutionalProfile
  1. PersonalEssay(Limit250words)

Theessayshouldbenomorethan250wordsandshouldconveywhythenomineeis interestedinparticipatingintheparticularInstitute,whats/heexpectstogain, andwhats/he willcontributetoInstitute.Thepersonal statementshouldalsoaddresshows/hewillleveragetheexperiencetoachieve"otherpotentialoutcomes"checkedintheabovesection.Inaddition, theessayshoulddescribethenominee'scapacity toamplify theimpactoftheprogrambeyondtheirresearchandknowledge.

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