Study in the United States Summer Institute

2012 Study in the United States Summer Institute

Application Form

Indicate Institute (Please indicate ONLY ONE Institute, otherwise your application will not be considered):

U. S. Culture and Society

American Politics and Political Thought

Contemporary American Literature

U. S. Foreign Policy: Foundations and Formulation

Journalism and Media

Religious Pluralism in the United States

Study of the United States Institutes for Secondary School Educators

Personal Information:

1.
	Family Name	First Name		Patronymic		Title (Dr./Mr./Mrs./Prof.)
	(NOTE: AS IT APPEARS IN HIS/HER PASSPORT.)
2.			3.		4.
	Date of Birth (MM/DD/YYYY)			City of Birth		Country of Birth
5.			6.
	Country of Residence			Country(ies) of Citizenship
7.
	Home Address
	Cell phone			Home Telephone		E-mail
	(NOTE: Please include the telephone code for your city or region.)
8.	Male	Female
9.	Medical, Physical, Dietary or other Personal Considerations:
Professional Information:
10.
	Current Position and Title			Department
11.
	Institution
	Address
	City
	Telephone			Fax
12.	Work experience, most recent first:
	Institution/Employer			Position		Dates of Employment
13.	Education, Academic and Professional Training, most recent first:
	Degrees/Fields of Specialization		Institution		Date
14.	Active professional memberships AND additional professional training:
15.	Short List of Relevant Publications (maximum 10 publications): Publications should include the publication year, type of publication, title, and publisher. All foreign titles should be translated into English. To identify the publication type, please choose from among the following options: 1) book; 2) edited volume (as primary or co-editor); 3) book chapter; 4) journal article; 5) newspaper/online article; 6) conference/university/government working paper.
16.	U. S. Travel:
	Purpose			Date		USG-funded
						Yes No
						Yes No
						Yes No
						Yes No
17.  17.	Family Residing in the United States: Please list any immediate family members who are currently residing in the United States, including city and state:
18.	English Proficiency:
	Reading:	Excellent		Good		Fair
	Writing:	Excellent		Good		Fair
	Speaking	Excellent		Good		Fair

19.  Professional responsibilities:

Current Courses taught – Please include the course title, level of students (Ph. D., M. A., Undergraduate, High School), and the number of advising hours.

Current Student Advising – Please include the number of students advised who are studying U. S. related topics, level of students (Ph. D., M. A., Undergraduate, High School), and the number of advising hours.

Other Potential Outcomes – Please select all of the likely potential outcomes that might result from your participation in this institute:

Update Existing Course;

Create New Course;

Create New Degree Program

University Curriculum Redesign;

National Curriculum Redesign;

New Research Project;

New Publication;

Professional Promotion;

Government or Ministry Policy;

New Professional Organization;

New Institutional Linkages;

Raise Institutional Profile.

Please explain each point marked.

20.  Personal Essays, limit 4,500 characters each.

1) Please discuss your professional responsibilities in greater detail, including how attending this Institute would help you achieve the "Other Potential Outcomes" you have checked above; AND 2) Please discuss 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 your home country.

Applications without essays will not be considered.

Completed applications may be sent by e-mail: *****@***com

Application deadline: November 30, 2011

Please phone (4if you have any questions.