Teaching ExcellenceandAchievementProgram(TEA)

InternationalTeacherApplication

AprogramoftheBureauofEducational andCulturalAffairs(ECA),U.S.DepartmentofState,andimplementedbyIREX

Please complete ALL information requested. Incomplete applicationswill notbe accepted.

TEACohortPreference:
Pleaseindicateyourprogramcohortpreference(*note:preferenceisnotguaranteed):
□CohortI□Cohort II□Nopreference
(January – March2017)(September–November2017)
Name(please spellexactly asitiswritten onyourpassport)
First/Given name:
Middle name:
Familyname/Surname:
Country
CountryofCitizenship:
CountryofLegal Residence:
Place of Birth
CityofBirth:
CountryofBirth:
Gender
MaleFemale
Number of YearsTeaching
Ihave beenteaching foryears(notincludingstudent teachingpracticums).
Date of Birth(aslistedonyour passport)
Month / Day / Year
Please check yourbirthmonth:
□January□February□March□April□ May□June
□July□August□September□October□November□December
Whatclasses doyouteach? (check allthat apply)
English
□English fornativespeakers□Englishfornon-nativespeakers□Englishliterature
□English Grammar□Other

9.HomeMailingAddress:

Street/BuildingNumberApartmentNumber

(ifapplicable)

CityorTownCountry

Region/Province/StatePostalIndex/Code

(ifapplicable)

Telephone numberMobileTelephone:

(country code+citycode+ number)(country code +city code+number)

E-mail:

10.SchoolAddress:

NameofSchool:

CityorTownRegion/Province/State

Country

11.SchoolInformation:
(a)Isyourschoolinanurbanorruralarea?
(b)Isyourschoolgovernment-runorprivate? / □Urban
□Government-run / □Rural
□Private

Total number of studentsat theschool:

Total number of hours you teach in high school:

Totalnumber of full-timeteachersat theschool:

Totalnumber of part-time teachers at the school:

Gradelevels at the school:

Agerange of students:

Averagenumberofstudentsperclass:

Inlessthan200words,pleasetellusbrieflyabout yourschoolandthecommunityitserves:Whoarethestudents?Whatdotheydowhentheyleaveschoolorcompletetheirstudiesat yourschool?Whatkindofwork dotheirparentsdo?Pleasebrieflyshareanyotherimportantinformationabouttheschoolcommunityhere.

12.HasateacheratyourschoolparticipatedinTEAortheInternationalLeadersinEducation(ILEP) program?If yes,whatishis/hername,theprogramandthedatesofparticipation?

□Yes□NoName(s):

Program:

DatesofParticipation:

13.AreyoucurrentlyapplyingtoanyotherU.S.governmentsponsoredprogram,includingonlineprograms?

□Yes□No

If yes, please specify which program:ProgramDates: Nameofsponsoringorganization:

14.Areyoucurrentlyapplyingordoyouplantoapplytoanyprofessionaldevelopmentprogramsinothercountries? □ Yes □No

If yes,please specifywhich program:ProgramDates: Nameofsponsoringorganization:

15.Inthechartbelow,pleasefillinanyprevioustripsyouhavetakenoutsideofyourhomecountry.Pleaseincludetripsfortourism,work,andexchangeprograms.AlsoincludeanytripssponsoredbytheU.S.government.Pleaseprovideasmanydetailsaspossibleinthe“Notes”column.

City,CountryVisited / YearofTravel / ReasonforVisit(Work/Tourism/ ExchangeProgram) / Notes
(Nameofprogram,programdetails,sponsoringorganization,etc.)

16.Pleaselistotherinternationalexposureyouhavehadincludingworkingwithinternationalorganizationsorforeignersinyourhomecountry.

17.DuringtheTEAProgram,participantsoftenhaveroommatesfromotherareasoftheworld.Whatstepswouldyoutaketosuccessfullylivewithapersonfromanothercountry?

18.HowdidyouhearabouttheTEAprogram?

□Colleague□ProgramAlumnus□Friend□SchoolAdministrator

□Fulbright mailing/social media:□ Fulbright website:

□Other:

19.Education:Pleaselistyoureducationalbackground.

Institution/School / #ofyearsofstudy / FieldofStudy / Degree/Certificate
(BA,BS, Masters, PhD,etc.) / YearofDegree

20.ForeignLanguageProficiency:Pleaserateyourproficiencyforeachlanguageyouknowinthecategoriesofreading,writing,comprehensionandspeaking.Pleaserateonscaleof1to5with1beinglow,and5beinghigh.

Language / Reading / Writing / Comprehension / Speaking

21.WorkHistory: Pleaselistbelowyourworkhistoryforthepastfive years.Pleaselistyourcurrentpositionfirst.

Onlyonesectionisnecessaryperschool,evenformultipleyears.

CurrentSchoolInformation

Nameofschool:Position/Title:

Lengthof employment (dates):Gradelevel(s) taught andage range of students: Numberofhoursperweekteaching:

Primary subjecttaught:Additionalduties:

PreviousSchoolInformation

Nameofschool:Position/Title:

Length ofemployment (dates):Gradelevel(s) taught and age range of students: Numberofhoursperweekteaching:

Primary subject taught:Additionalduties:

PreviousSchoolInformation

Nameofschool:

Position/Title:

Length of employment (dates):Gradelevel(s) taught and age range of students: Numberofhoursperweekteaching:

Primary subject taught:Additionalduties:

22.AdditionalEducationorProfessionalExperienceActivity:Pleaselistwhatactivities youhavepursuedinsideandoutsidetheclassroomtomaintainyourprofessionaltrainingasaneducator.Inaddition,pleaselistprofessionalorganizationsthatyouareamemberofandrelevantworkinyourcommunityoutsideofschool.

23.ClassroomLesson: Pleaseattachalessonplanthatyouhaveusedinyourclassroomandanswerthefollowingquestions:Howdidyouplan/designthelesson?Howwasthelessonreceivedbyyourstudentsandhowdidyouassessyourstudents’learning?

24.WeeklySchedule:

School NameDayofthe

Week

Timeof DayLengthofclass/responsibility(inminutes)

SubjectGradeLevelNumberofStudentsintheClass

Ageofstudents

Monday9:00-9:45am45minutesGeographyGrade955Students14-15

Monday10:00-10:55am55minutesCivicsGrade1045Students16-17

Monday1:00-1:45am45minutesHistoryGrade1040Students16-17

Monday2:00-3:00am60minutesPrep

Tuesday8:30-9:25am55minutesCivicsGrade1045Students16-17

Pleaseprovideasampleofyourweeklyschedule.Thisshouldincludeallclasses youarecurrentlyteachingincludingplanningandpreptime,aswellasadditionalresponsibilitiesoutsideofteaching.If youteachinmorethanoneschool,pleaseindicatetheschoolname.Asampleisprovidedabove.

YourSchedule:

School Name / Dayof theWeek / Time of Day / Length ofclass/responsibility (in minutes) / Subject / GradeLevel / Number of StudentsintheClass / Age of Students

APPLICANTNAME:

COUNTRY:

24(continued).WeeklySchedule

School Name / Dayof theWeek / Time of Day / Length ofclass/responsibility (in minutes) / Subject / Grade / Number of StudentsintheClass / Age of Students

25.StatementofPurpose: YourStatementofPurposeisthemostimportantpartof yourapplication.Yourresponsewillgivetheselectioncommitteeanopportunitytobetterunderstandyouasateacherleaderandyourdesiretoparticipateintheprogram.Statementsmustbeclearlywritteninordertobeconsidered.

Inthespaceprovided,pleaseaddressallquestionsinnomorethan500words:

□Describeanoccasionwhenyouwerealeaderorsetapositiveexamplein yourschool.

□Whatskillsandexperiencedo youhopetogainfromparticipatingintheTEAProgram,andhowwillthesebenefityouandyourcommunityonceyouhavecompletedtheprogram?Describeatleasttwoways youwillsharetheseskillswithyourschooland/orcommunity.

□WhydoyouwanttoparticipateintheTEAProgram?

AdditionalSpace:Pleaseusethisspaceforanyadditionalinformation.Includeanyresponsesthatdidnotfitelsewhereintheapplication.

IREXPRIVACYPOLICYAPPLICATION CERTIFICATION STATEMENT

YourprivacyisimportanttoIREX.Thatiswhywerequestthatallapplicantsreadthefollowingprivacypolicystatementcarefully.

1.APPLICANTANDPARTICIPANTINFORMATION CONTENTANDSTORAGE

Informationaboutprogramapplicantsandcurrentand pastparticipantsconsistsofdatacontainedintheirapplications,informationderivedfrominterviews,andinformationgatheredduringthecourseoftheirprogramandasprogramalumni. IREXstoresthisinformation inwritten andelectronicformindefinitely.Somedata, suchascontactinformationandprofessionalexperience,iscontinuallyupdated.

2.USEOFINFORMATION:Information,whichisdescribedabove,maybe:

A.Usedbyselectioncommitteesandinterviewerstoreviewapplicants;

B.Suppliedtotheprogram’sfundingorganization;

C.Submitted to potential host schools, universities, or organizations and/or organizations that provide fieldexperienceopportunities;and

D.Usedfortheevaluationofanindividual’sparticipationintheprogramandinthecollectionofdataforgeneralprogramevaluationbyIREX,fundingagenciesorotherorganizationscontractedtoconductevaluations.

IREXdoesnotsellapplicantorcurrent/pastparticipantinformation.

TheprinciplesstatedhereinarebindingonlytoIREX;otherorganizationsinvolvedintheimplementationoftheseprogramsmayadheretootherprivacyorsimilarpolicies.

3.CERTIFICATION:IcertifythatIcompletedthisapplicationmyself,withoutanyaidorassistance,thattheinformationgiveninthisapplicationiscompleteandaccurate,andthatIhavecarefullyreadandunderstandallnotesanddisclaimersprovidedtherein.

IunderstandthatIREXreservestherighttoverifyalltheinformationlistedintheapplication.IunderstandthatgivingfalseormisleadinginformationintheapplicationwillresultinexclusionfromthecompetitionorimmediatedismissalfromtheTeachingExcellenceAchievement(TEA)program.

Also,IacknowledgethatIam awareofthefollowingrequirementsthatImustobserveifIam selectedfortheprogram:

  • Imust abidebyallprogramrules andregulationsandobserveallthelawsoftheUnitedStates duringmystaythere,includingreturningtomyhomecountryforatleasttwoyearsattheconclusionoftheprogramincompliancewithJ-1visarequirements.
  • Themedicalinsuranceprovidedtomeduring mytravelsisintendedonlyforemergenciesanddoesnotcoverordinary,pre-existing,anddentalconditions.
  • Myspouse,children,otherrelativesorindividualsarenotpermittedto accompanyme to theUnited Statesontheprogram.

SignatureofApplicant(must behandsigned)Date