UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN by 3KWxOOoP

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									             UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN
                    Application to Establish a Cooperative Agreement
                                 with a Foreign Institution


1. Name and Country of Partner Institution:

2. Proposed duration of agreement:
   Starting date: ## / ## / #### _________Ending date: ## / ## / ####

3. Principal Initiator(s) at UIUC:
    Name:
    Department/Office:
    Rank/Title:
    Address, Phone, E-mail:
    Name:
    Department/Office:
    Rank/Title:
    Address, Phone, E-mail:

4. Principal Initiator at partner institution:
    Name:
    Department/Office:
    Rank/Title:
    Address, Phone, E-mail:

5. Purpose(s) of agreement:          Teaching            Research      Study Abroad
        Technical Assistance             Consulting/Advising           Work/Internship
        Professional Development         Language Acquisition               Public Service
       Other (Please Specify)

6. Eligible Participants:      Faculty           Staff        Graduate Students
        Undergraduate Students                   Others (please specify)
                                  Application to Establish an International Cooperative Agreement, Page 2




7. Collaborative project abstract (please provide a brief summary of planned collaborative
activities to be undertaken with the proposed partner institution, planned timeframe for
implementation, budget and funding sources, method of assessing successful outcomes, and the
overall value of the partnership to the sponsoring unit, and to the campus as a whole:



                                  Approval and Certification

I certify that, to the best of my knowledge, the information provided on this form is correct and
complete. In the event that this exchange is approved, I agree to abide by all applicable
institutional, partner, and sponsoring agency policies and procedures of the University of Illinois
at Urbana-Champaign and at [name of foreign institution]


Signature(s) of Principal UIUC Initiator(s):

_______________________________________                Date: _______________________
(Name)

_______________________________________                Date: _______________________
(Name)

Signature(s) of Department Head(s) and/or Division Head(s):                   [REQUIRED]

_______________________________________                Date: _______________________
(Name)

_______________________________________                Date: _______________________
(Name)

Signature(s) of Academic Dean(s):

_______________________________________                Date: _______________________
(Name)

_______________________________________                Date: _______________________
(Name)
Please return completed form to:
Director, Illinois Strategic International Partnerships (ISIP)
Office of the Associate Provost for International Affairs
507 E. Green Street, Suite 401 (MC-417)
Champaign, IL 61820
(217) 333-1990 tebarnes@illinois.edu

								
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