2014 Study of the United States Institutes for Faculty and Scholars APPLICATION FO !

A. Title of the U.S. Studies Institute you are applying to

B. Candidates Full Name, exa tly as it appears on passport Prefix: Last Name: First Name: Middle Name: C. !ender Male Female Dr. Miss Mr. Mrs. Ms. Prof.

". "ate of Birth (mm/dd/yyyy): #. Birth City$ F. Birth Country$ !. Citi%enship Primary: Secondary: (if applicable) &. Country of 'esiden y$ I. (edi al, )hysi al, "ietary or other )ersonal Considerations Disability: Blind and is!al "mpairments P#ysical Disabilities Psyc#iatric Disabilities

Deaf and $earin% "mpairments Learnin% Disabilities

Please describe any pre&existin% medical conditions' incl!din% any prescription medication yo! may be ta(in%' or ot#er dietary or personal consideration. )#is *ill not affect t#e candidate+s selection' b!t *ill enable t#e #ost instit!tion to ma(e any necessary accommodations.

*. Candidate Conta t Information ,ddress:

-ity: $ome State or Pro.ince: Postal -ode: $ome -o!ntry Name: /mail: P#one (incl!de area code): -ell (incl!de area code): -ontact name 0 relations#ip: /mer%ency -ontact P#one: /mer%ency -ontact /mail: +. Current )osition, Title, Institution Position )ype: Senior 1ni.ersity 2fficial (President' Pro.ost)' 3o.ernment Minister' Senior /xec!ti.e' etc. 1ni.ersity Dean' 3o.ernment ,d.isor' ice President' 4!nior /xec!ti.e'

Senior Professor' Department -#air' Director' /ditor' 2fficer' etc. ,ssociate Professor' Senior 5esearc#er/)#in(&)an( Fello*' Senior Staff' etc. ,ssistant Professor' ,ssistant /ditor' -oordinator' mid&le.el Staff researc#er/)#in(&)an( fello*' etc. Lect!rer' )eac#er' -ons!ltant )eac#in% ,ssistant' "nstr!ctor 2t#er )itle: "nstit!tion Name: "nstit!tion -o!ntry: ,ddress: P#one (incl!de area code): ,. -or. experien e, in luding pre/ious positions and titles$ From: )o: )itle/"nstit!tion (Please specify if position is part&time

(. #du ation, A ademi and )rofessional Training$ Please list all earned de%rees be%innin% *it# most recent. De%rees listed s#o!ld reflect t#e closest 1.S. e6!i.alent. De%ree /arned: 7ear earned: (Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree) Speciali:ation/"nstit!tion: De%ree /arned: 7ear earned: (Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree) Speciali:ation: De%ree /arned: 7ear earned: (Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree) Speciali:ation: De%ree /arned: 7ear earned: (Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree) Speciali:ation: De%ree /arned: 7ear earned: (Doctorate/4.D./etc8 -andidate/,BD8 M.,.8 3rad!ate -ertificate8 B.,.8 ,ssociates/9 yr. De%ree) Speciali:ation: Additional )rofessional Training$

N. A ti/e )rofessional (em0erships$ ,cti.e Professional Members#ips independent of c!rrent professional responsibilities. )#ese s#o!ld not incl!de !ni.ersity committee *or( or ot#er professional d!ties directly related to c!rrent employment. Position )itle 2r%ani:ation

1. )u0li ations 'elated to the Institute Theme 2up to 345 Please list all forei%n titles in /n%lis#' incl!din% *#et#er boo(' c#apter' ;o!rnal article' ne*spaper article' *eb article' etc. P!blication )ype: 7ear:
(Boo(//dited ol!me/-#apter (boo()/4o!rnal ,rticle/<or(in% Paper/2pinion Piece/<eb ,rticle)

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P!blication )itle/P!blis#er: ). )re/ious #xperien e in the United States P!rpose of .isit: From: )o: Description: P!rpose of .isit: From: Description: P!rpose of .isit: From: Description: )o:

(mm/dd/yyyy)

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(mm/dd/yyyy)

6. Family7Friends 'esiding in the United States$ Please incl!de city and state (/xample: 4o#n Doe = -#ica%o' "L)

'. #/iden e of #nglish Fluen y$ Preferably an "B )2/FL or "nstit!tional )2/FL score. "n t#e e.ent /n%lis# score is not a.ailable' applicants s#o!ld complete t#e attac#ed /n%lis# proficiency e.al!ation form.

S. )rofessional 'esponsi0ilities$ Please disc!ss yo!r professional responsibilities in %reater detail' incl!din% researc# interests' administrati.e responsibilities (ex. -!rric!l!m desi%n)' and/or ot#er pertinent information.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Current Courses Taught$ -o!rse title: Le.el of st!dents (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool): -lassroom #o!rs per semester: N!mber of st!dents:

/stimated percent of 1.S. St!dies content: -o!rse title: Le.el of st!dents (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool): -lassroom #o!rs per semester: N!mber of st!dents: /stimated percent of 1.S. St!dies content: -o!rse title: Le.el of st!dent (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool): -lassroom #o!rs per semester: N!mber of st!dents: /stimated percent of 1.S. St!dies content: Please copy format as needed for additional co!rses: 8888888888888888888888888888888888888888888888888888888888888888888888 Current Student Ad/ising$ ,d.isin% is not t#e same as teac#in%. <e are loo(in% for t#e n!mber of st!dents' t#eir le.el' and #o!rs t#e nominee spends pro.idin% assistance in #elpin% st!dents clarifyin% personal and career %oals' and e.al!atin% pro%ress to*ards t#ose %oals. )#is section can also incl!de t#ose t#at s!per.ise P#D and %rad!ate st!dents. N!mber of st!dents ad.ised *#o are st!dyin% 1.S. related topics: Le.el of st!dent (P#.D.' M.,.' 1nder%rad!ate' $i%# Sc#ool): N!mber of ad.isin% #o!rs: >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 1ther )otential 1ut omes$ Please select any li(ely potential professional o!tcomes of t#is pro%ram. 1pdate existin% co!rse -reate ne* de%ree pro%ram National c!rric!l!m redesi%n Ne* p!blication 3o.ernment or Ministry Policy Ne* instit!tional lin(a%es -reate ne* co!rse 1ni.ersity c!rric!l!m redesi%n Ne* researc# pro;ect Professional promotion Ne* professional or%ani:ation 5aise instit!tional profile

T. )ersonal #ssay Limit 9?@ *ords. A) Please disc!ss #o* yo!r participation *o!ld en#ance yo!r personal and professional %oals' t#e c!rrent state of 1.S. St!dies in yo!r #ome co!ntry' or !pon t#e "nstit!te. "ncl!de #o* attendin% t#is "nstit!te *o!ld #elp yo! ac#ie.e t#e B2t#er Potential 2!tcomesC yo! #a.e c#ec(ed abo.e.

Please enclose the following: - Your full CV in English, if readily available if not, in Spanish. support letter fro! your i!!ediate supervisor endorsing your candidacy and confir!ing your availability to travel if selected as well as the "epart!ent#s or institution#s interest in developing or enhancing $.S. Studies. %he letter !ay be written in Spanish and should be addressed to: &s. Stephanie Sypta'-(a!nath Cultural ffairs )fficer $.S. E!bassy &e*ico, ". +. Please sub!it your application for! and acco!panying docu!ents as an E!ail attach!ent to: solicitudesbecas,state.gov. %he sub-ect of the e-!ail should be your first na!e, last na!e and the .nstitute you are applying to. E*a!ple: &argarita /on01le0 2 3456 S$S. $.S. Culture and Society "E "7.8E: 9anuary 5:, 3456 +or further infor!ation on the .nstitutes please contact: Citlali &ill1n Cultural ffairs )ffice Public ffairs Section $.S. E!bassy &e*ico E!ail: !illangc,state.gov