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Fulbright American Studies Summer Institute

Training Program in the United States
Application Form

1. Name
___________________________________________________________________________
Family Name First Patronymic Title
(Dr./Mr./Mrs./Prof.)
2. Position __________________________________Department
_____________________________

Dept. Tel.__________________ Fax__________________ E-mail
__________________________
(NOTE: Please include the telephone code for your city or
region.)
Institution
________________________________________________________________________

Address
_________________________________________________________________________

City _____________________________________
Country________________________________

3. Home address ____________________________ Home Tel.
______________________________

City_____________________________________ Country

4. Citizenship: ______________________________External Passport Number:
_________________

5. Place of Birth______________________6. Date of Birth
_________________________________
Month/Day/Year
7. Female _____ Male _____ 8. Single_____ Married_____

9. English Proficiency: Reading: Excellent___ Good___ Fair___
Writing: Excellent___ Good___ Fair___
Speaking: Excellent___ Good___ Fair___

10. Highest degree earned: _____ diplom _____ kandidatskaya _____
doctorskaya

11. In what field
______________________________________________________________________

12. Colleges, universities, professional schools attended, most recent
first (use additional pages if necessary)

Institution and city Year Attended Discipline/Field
Degree/Date

_______________________ _________________ ________________
_____________

_______________________ _________________ ________________
_____________

_______________________ _________________ ________________
_____________

_______________________ _________________ ________________
_____________



13. Academic or professional positions, most recent first:

Institution/Employer Position Dates of
Employment

_________________________ ______________________
___________________

_________________________ ______________________
___________________

_________________________ ______________________
___________________

_________________________ ______________________
___________________

14. List cultural, educational, and professional societies of which you
are a member.


____________________________________________________________________________
_______




15. Overseas travel (countries, dates and purpose of visit during the
past 5 years).


____________________________________________________________________________
______







16. Names and dates of professional honors, awards, fellowships,
scholarships.
(Attach additional pages if necessary)





____________________________________________________________________________
____



____________________________________________________________________________
_____


17. Please list any publications with title, publication date, and where
published.
(Attach additional pages if necessary)


____________________________________________________________________________
______


____________________________________________________________________________
_____


____________________________________________________________________________
______


____________________________________________________________________________
_______


____________________________________________________________________________
______


____________________________________________________________________________
_____





I certify that the information given in this application is complete and
accurate to the best of my knowledge. I understand that final approval of
my application is dependent upon my eligibility for a visa to the United
States. I agree to return to my home country upon the expiration of my
authorized stay in the United States.

__________________________________________ ______________________________
Signature Month/Day/Year



Please attach a two-page essay in English describing:

- Current teaching responsibilities in the field of American studies;
- Commitment to the development of curriculum for implementation at your
home university;
- Interest in improving professional environment at home university;
- Demonstrated or recognized capability to positively affect students'
learning;
- Ability to act as cultural and academic resource;
- Expectations of what you wish to gain from a training program in the
United States, and how it will be used in your future teaching/curriculum
development activities.

Please make your remarks practical and professionally relevant.

Applications without essays will not be considered.

Completed applications may be sent to: Educational Exchanges Office, Public
Affairs, American Embassy, Bolshoy Devyatinskiy per., 8, Moscow 121099
Applications may be faxed to: (095) 728-52-62
Applications may be e-mailed to: MitoussovaN@state.gov and LvovaM@state.gov

Please phone 728-53-65 if you have any questions.
Application deadline: February 23, 2004