FULBRIGHT

FULBRIGHT SCHOLARSHIP APPLICATION
FOR STUDY IN THE UNITED STATES AND FINANCIAL
FULBRIGHT
CHECK BOX FOR SCHOLARSHIP:
FIELD OF STUDIES:
FULBRIGHT MA, MS, MBA, PHD
TEACHER EXCHANGE
H.H. HUMPHREY
(Circle degree choice)
AMERICAN INSTITUTES
PERUVIAN VISITING PROFESOR - SCHOLAR IN RESIDENCE
1. Full name as it appears on your passport or DNI, with your last name in capital letters:
2. Address:
3. E-mail
address:
4. Country of permanent legal residence:
6. Sex:
Female
5. Country of citizenship:
Male
7. Do you hold U.S. citizenship or have permanent U.S. residency? NO
8. Date of Birth:
9. Place of Birth:
day / month / year
10.Where have you lived for the greater part of your life?
City or Town / Province / Country
11. How did you learn about this scholarship?
12. If you have previously applied for or received a Fulbright scholarship, indicate year, country, grant category, and whether the grant was
awarded:
Year:
Country:
Scholarship category:
Awarded?
13.
Teléfono Casa:
Teléfono Oficina:
Número de FAX:
Signature:
Teléfono Celular:
Teléfono de Emergencia:
DNI Nº:
Date:
Yes
No
APPLICATION FOR STUDY IN THE UNITED STATES AND FOR A FELLOWSHIP,
SCHOLARSHIP, ASSISTANTSHIP OR OTHER EDUCATIONAL GRANT
FULBRIGHT
(Please read instructions carefully. All sections should be completed in English and be typewritten.)
1. NAME OF APPLICANT
Mr.
Last Name
Middle
Initial
First Name
Mrs.
Ms.
2.
MAILING ADDRESS:
3.
PLACE AND DATE OF BIRTH (City or town, and country)
4.
COUNTRY OF YOUR PRESENT CITIZENSHIP
5. COUNTRY OF RESIDENCE
6.
MARITAL STATUS (single, married, widowed or divorced)
7. LIST AGES OF CHILDREN, IF ANY
8.
STUDY PLANS: (Read instructions carefully before completing this section)
INSTITUTE OF INTERNATIONAL EDUCATION PLACEMENT SERVICES
DIVISION
809 UNITED NATIONS PLAZA, NEW YORK, NY 10017-3580
Month
Day
Year
(a) WHAT IS YOUR PROPOSED MAJOR FIELD OF STUDY AND IN WHAT SPECIFIC AREA OF YOUR FIELD DO YOU PLAN TO SPECIALIZE?
(b) DEGREE OBJECTIVE:
Master's
Doctorate
Non degree
Other:
(c) WRITE A CLEAR AND DETAILED DESCRIPTION OF YOUR STUDY OBJECTIVES, and give your reasons for wanting to pursue them in the U.S.
Be specific about your major field and your specialized interests within this field. Describe the kind of program you expect to undertake, and explain how your
study plan fits in with your previous training and your future objectives.
Your statement is an essential part of your application. Unclear, incomplete or impractical proposals can result in your being referred to a
university not suited to your scholastic needs, or your not being accepted by any university. DO NOT name specific universities at which
you would like to study.
Application-Page 1
NAME OF APPLICANT:
FULBRIGHT
COUNTRY:
8. (c) STUDY OBJECTIVES (Continued):
9. TEACHING EXPERIENCE: Describe any teaching positions you have held or currently hold.
10.
RESEARCH: Describe any research you have completed or in which you are currently involved.
11. FUTURE PLANS: Describe the career you plan to pursue after completion of study or research in the U.S. (e.g., teaching, government,
business, industry or any plans you might have for continued study or research in your home country). Also indicate if you will be returning
to former employment, or if you have been promised a position in your home country after completing your U.S. training.
12. EDUCATION: List educational institutions attended, and any in which you may be presently enrolled.
INSTITUTION AND LOCATION
(List chronologically)
MAJOR FIELD OF STUDY
DATES (Month and year)
From
To
ACTUAL NAME OF
DEGREE OR DIPLOMA
(Do not translate)
DATE
RECEIVED
OR EXPECTED
Application-Page 2
NAME OF APPLICANT:
FULBRIGHT
COUNTRY:
13. LIST SCHOLARSHIPS OR FELLOWSHIPS HELD AT PRESENT, OR IN THE PAST: (Give source or sponsor, amount, where held, and duration
amounts.)
14. INDICATE ANY ACADEMIC HONORS OR PRIZES WHICH YOU HAVE RECEIVED
15. LIST BELOW ANY BOOKS, ARTICLES OR THESE PUBLISHED BY YOU, ESPECIALLY IN YOUR PROPOSED FIELD OF STUDY: (Give title, place and date
of publication.)
16. KNOWLEDGE OF LANGUAGES, INCLUDING ENGLISH (Rate yourself Excellent, Good or Fair. Include all languages in which you have some
competence. Indicate mother tongue.)
NAME OF LANGUAGE
READING
WRITING
SPEAKING
English
17. OCCUPATIONAL EXPERIENCE: LIST POSITIONS HELD (Begin with the most recent employment, if any.)
DATES (Month and year)
TYPE OF WORK
NAME AND ADDRESS OF EMPLOYER
To
From
18. LIST PROFESSIONAL SOCIETIES, FRATERNITIES OR OTHER ORGANIZATIONS IN WHICH YOU NOW HOLD MEMBERSHIP OR IN WHICH YOU HAVE
BEEN ACTIVE IN THE PAST (Indicate if you have held an elective office.)
19. IF YOU HAVE TRAVELLED OR LIVED IN ANY COUNTRY OTHER THAN YOUR OWN INDICATE PLACES, DATES AND REASONS
21. PLEASE LIST ANY CLOSE RELATIVES OR
FRIENDS IN THE UNITED STATES (Name,
address and relationship)
20. PLEASE PROVIDE THE NAME, ADDRESS AND TELEPHONE NUMBER OF INDIVIDUALS
TO BE NOTIFIED IN CASE OF AN EMERGENCY
IN YOUR HOME COUNTRY
IN THE UNITED STATES
22. PLEASE DESCRIBE ANY PHYSICAL IMPAIRMENT YOU MAY HAVE
This information is gathered for statistical purposes and to ensure appropriate placement. The Fulbright Program does not discriminate on the basis of race, color,
religion, sex, national origin, and/or physical impairment.
23. DO YOU NOW HAVE, OR HAVE YOU EVER HELD:
U.S. CITIZENSHIP?
Yes
No
DUAL CITIZENSHIP?
Yes
No
BY MY SIGNATURE, I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION PROVIDED IN MY APPLICATION IS ACCURATE AND COMPLETE.
SIGNATURE OF APPLICANT:
DATE:
______
Application-Page 3
NAME OF APPLICANT:
NAME OF APPLICANT:
FULBRIGHT
COUNTRY:
CURRICULUM VITAE
This Curriculum Vitae should be a narrative statement concerning your professional, academic and future plans. It should not be a mere listing of
facts. It should include information about your education, practical experience, special interests, career plans, and your purpose in applying for
study in the U.S. Describe any significant factors that have influenced your educational or professional development. Advanced students should
comment on the number of years of practical experience already completed in the field in which academic work will be done in the U.S. and
describe briefly the most advanced courses already pursued in their field of study. (Do not mention specific U.S. institutions in your Curriculum
Vitae.)
Curriculum Vitae
FULBRIGHT
CONFIDENTIAL INFORMATION FORM
TO BE COMPLETED BY THE APPLICANT
I.
Are there any U.S. universities at which you would prefer to study?
Yes
No
Yes
If "Yes", are you certain that these universities have departments offering your proposed academic program and your desired degree?
No
If you wish, list in priority order no more than three schools of your choice. IIE will take your preferences into consideration insofar as possible. Be sure to give
detailed reasons for each choice, and confirm that these universities offer programs in your field of interest.
University Preferred
Graduate Department (If Applicable)
Specific Reason for Preference
1.
2.
3.
II. It is not expected that you will apply for admission by direct application or correspondence with a university in the United States.
(a) If, however, you have already submitted an application form directly to any universities in the U.S., list the names of these institutions below and
indicate the response you have received, if any.
University
Response to Application
Date of Application
(b) If you have corresponded with department professors and/or admissions offices at any U.S. universities, list the names of these universities and
contacts below and attach copies of all your correspondence with them. Correspondence only does not constitute an application for admission.
University
Name of Department, Professor, or Other Office or Person Contacted
IIE will follow up, as necessary, on the contacts you have listed above. Should you have additional direct contacts with U.S. schools, you must immediately notify
your Selection Committee.
III.
Indicate if you are planning to apply for a fellowship, scholarship, assistantship or other educational grant or loan form another organization,
government or educational institution: (This information will not prejudice your application to IIE.)
IV.
In order for a university to admit you to a program suitable to your academic objectives, it is important to be precise in answering this question.
(a) After discussing your degree objectives with your Selection Committee, please circle the university degree, if any, you want to obtain at a U.S.
university:
1. Bachelor's
2. Master's
3. Doctorate
4. No Degree
(b) If "No Degree", are you willing to study in a degree program should it not be possible to place you in a nondegree program?
(c) If "Yes", circle the degree preferred:
V.
1. Bachelor's
2. Master's
Yes
3. Doctorate
If required, will you be able to arrive for an introductory orientation and/or English course in June, July or August?
Yes
No
If "Yes", indicate the earliest possible date by which you could arrive for such a program:
If "No", please explain why:
VI.
The U.S. academic year begins in late August or September. If you cannot arrive in the United States by that time, please
explain why:
VII. MILITARY SERVICE: Will you be able to arrange postponement if compulsory military duty conflicts with your proposed study period in the United States?
Yes
No
Confidential Information Form-Page 1
No
FULBRIGHT
CONFIDENTIAL INFORMATION FORM (Continued)
STANDARDIZED TESTS
If you have taken or are planning to take any of the following tests, please indicate the date of the test.
Test of English as a Foreign Language (TOEFL)
Test of Spoken English (TSE)
Test of Written English (TWE)
Graduate Record Examination (GRE)
Graduate Management Admission Test (GMAT)
Scholastic Aptitude Test (SAT)
Achievement Tests
Other (please specify)
N.B. Should you be unable to take the test(s) on the above date(s), please be sure to notify IIE through the Selection Committee.
IMPORTANT:
YOU MUST INDICATE THAT YOU WANT YOUR SCORE REPORTS SENT TO:
INSTITUTE OF INTERNATIONAL EDUCATION (IIE)
CODE NUMBER 2326
YOU MUST BE SURE TO INDICATE THIS CODE (2326) ON THE REGISTRATION FORMS OR ON THE ANSWER SHEETS PROVIDED AT THE TIME YOU TAKE THE EXAMINATION.
AUTHORIZATION FOR RELEASE OF INFORMATION
PLEASE SIGN BELOW AS YOUR AUTHORIZATION FOR IIE:
(1)
TO RECEIVE, AND/OR TO REQUEST YOUR TOEFL, TSE, TWE, GRE, GMAT, SAT, ACHIEVEMENT TESTS OR ANY OTHER
TEST SCORE REPORTS TO BE SENT TO U.S. ACADEMIC INSTITUTIONS ON YOUR BEHALF.
(2)
TO RECEIVE INFORMATION ON THE STATUS OF YOUR APPLICATION, INCLUDING FINAL DECISIONS, FROM U.S.
ACADEMIC INSTITUTIONS.
SIGNATURE OF APPLICANT:
DATE:
_______
Confidential Information Form-Page 2