SUSI 2011 Application Form-1 by ajizai


									                         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:
      Family Name                  First Name                  Patronymic                            Title (Dr./Mr./Mrs./Prof.)
2.                                                        3.                                    4.
      Date of Birth                                            City of Birth                         Country of Birth
5.                                                        6.
      Country of Residence                                     Country(ies) of Citizenship

      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:
      Current Position and Title                               Department



      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

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 – 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:

Application deadline: November 1, 2011

Please phone (495) 728-52-42 if you have any questions.

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