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2011 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 City of Birth Country of Birth (MM/DD/YYYY) 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: 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 1 17. Family Residing in the United States: Please list any immediate family members who are currently 7 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 – Should include the course title, level of students (Ph.D., M.A., Undergraduate, High School), and the number of advising hours. Current Student Advising – Should 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: 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. 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: USGExchanges@gmail.com Application deadline: November 1, 2011 Please phone (495) 728-52-42 if you have any questions.
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