SUSI Application Form
- Title of Institute (SUSI):
- Nominee's Full Name, exactly as it appears oncandidate’s passport.
Prefix
Last name
First name
Middle name
- Gender
- Date of Birth (please spell out Month/d/y)
- Birth City
- Birth Country
- Citizenship
- Residency
- Medical, Physical, Dietary or other Personal
Considerations: Please state if the candidate has anyexisting medical conditions or is currently taking anyprescription medication. This will not affectcandidate selection, but will enable the hostinstitution to make any necessary accommodations.
- Candidate’s contact information:
Street/House number/Flat number
City
Postal code
Country
E-mail:
Phone(s)
Contact name and relationship (e.g. name, surname, husband/wife)
Emergency phone
Emergency e-mail
- Current Position, Title, Institution’s complete address
- Work Experience, including previous positions andtitles
From (year, month, day)To (year, month, day)Position InstitutionFull/Part time
- Education, Academic and Professional Training.Please list all degrees earned beginning with the most recent.
Degree earnedYearSpecializationInstitution
Additional Professional Training
- Active Professional Memberships. These should not include university committee work or other professional duties directly related to current employment
PositionTitleOrganization
- Publications related to the SUSI theme(please do not list any more than 10)
Publication typeYearTitle in EnglishPublisher
- Previous Experience in the United States:
Purpose FromToDescription
Q. Family/Friends Residing in the United States: Please include city and State
R. Evidence of English Fluency (e.g. test score, self-evaluation, etc.)
S. Professional Responsibilities. Please discuss your professional responsibilities in a greater detail, including your research interests, administrative responsibilities, and other pertinent information.
Current Courses Taught:
Course titleLevel of StudentsClassroom hours per semesterStudent Number
U.S. Studies Content (%)
Current Student Advising
Number of students advised studying U.S. related topics
Level of students
Number of Students
Hours of Advising per student per year
Other Potential Outcomes(please mark)
Update existing course
University curriculum redesign
New publication
New professional organization
Create new course
National curriculum redesign
Professional promotion
New institutional linkages
Create new degree program
New research project
Government or Ministry policy
Raise institutional profile
T. Personal Statement/essay (250 words)
Please discuss how your participation would enhance your personal and professional goals, the current state of the U.S. studies in your institution and your home country. Include how attending this institute would help you achieve the “other potential outcomes” you have checked above.