The Summer 2017 Study of the U.S Institutes for
Foreign Scholars and Secondary School Educators

Application Form

All information should be in English and presented as follows:

*Application must be typed. Hand-written applications will be disqualified.

A. Title of Institute:…………………………………………………………………………

*Please indicate which of the seven subject areas you are applying for.

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B.First name: ………………………………

C. Gender: …………………………………

D. Date of Birth(mm/dd/yyyy):…………..

E. Birth City: ………………………………

Last name: ………………………………

F.Birth Country: …………………………

G.Country(ies) of Citizenship: …………..

H. Country of Residence: …………………

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I. Medical, Physical, Dietary or other Personal Considerations:

Disability:…………………………………………………………………………………..

………………………………………………………………………………………………

This will not affect candidate selection, but will enable the host institution to make any necessary accommodations.

J. Candidate Contact Information:

Address: …………………………

City:…………………………

Home State or Province:…………………………

Postal Code:…………………………

Home Country:…………………………

Email:…………………………

*If you do not have an active email address, please create one, and indicate it here.

Phone:…………………………

K. Emergency Contact Information:

Name and Relationship:………………………… (Example: John Doe, Husband)

Email:…………………………

Phone (work, mobile):…………………………

L. Current Position type, title, institution name, and country:

Title / Organization name

M. Work Experience, including previous positions and titles, and the approximate dates of employment:

From / To / Title/Institution (Please specify if position is part-time)

N. Education, and Academic and Professional Training:

*Please list all earned degrees and any and all current teacher qualifications you have such as certificates, licensures beginning with the most recent.

Degree earned / Year earned / Specialization/Institution

*Please list Professional Trainings below:

…………………………

…………………………

O. Active Professional Memberships (including position, title and organization):

Position / Title / Organization

P. Publications Related to the Institute:

Publications should include the publication year, type of publication, title, and publisher. All foreign titles should be translated into English. (Please list no more than 10.)

Publication type / Year / Title Publisher

Q. Previous Experience in the United States:

*if yes, please specify below.

From: ………………………… To: …………………………

Purpose: …………………………………………………………………………….………..

Additional Prior U.S. Visit: ………………………………………………………………….

R. Family Residing in the United States(please list)::

*If yes, please specify below. Please include name, city and state (Example: John Doe – Chicago, IL)

……………………………………………………………………………………………………………………………………………………………………………………………………

S. Evidence of English Fluency (e.g. personal interview, test score, etc.):

……………………………………………………………………………………………………………………………………………………………………………………………………

T. Professional Responsibilities:

*Please give a narrative description on the main duties of your current job.

……………………………………………………………………………………………………………………………………………………………………………………………………

Current Courses Taught:

Please list the course title, level of students (Ph.D., M.A., BSc, highschool), number of hours per semester, number of students, and the estimated percent of U.S. studies content.

Course tittle / Level of Students / Classroom Hours per semester / Number of Students / U.S. Studies Content (%)

Current Student Advising:

Please include the number of students advised who are studying U.S. related topics, level of students (Ph.D., M.A., BSc, high school), and the number of advising hours.

Activity / Number of students advised who are studying U.S. related topics / Level of Students / Hours of Advising Per students Per Year

Other Potential Outcomes:

Please mark details of the likely potential outcomes that might result from your participation in this Institute:

  1. Update Existing Course;
  2. Create New Course;
  3. Create New Degree Program;
  4. University Curriculum Redesign;
  5. National Curriculum Redesign;
  6. New Research Project;
  7. New Publication;
  8. Professional Promotion;
  9. Government or Ministry Policy;
  10. New Professional Organization;
  11. New Institutional Linkages;
  12. Raise Institutional Profile.

U. Personal Essay (no more than 250words) should discuss:

a)Your professional responsibilities in greater detail, including how attending this Institute would help you achieve the “Other Potential Outcomes” as described above, AND

b)How your participation would enhance this Institute, based either upon your personal and professional experience or upon the current state of U.S. studies in Mongolia.

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