Education, Academic and Professional Training, including degrees earned and fields of specialization

A Program of the Bureau of Educational and Cultural Affairs of the

United States Department of State

1. Name (Please write your complete name in Latin letters, EXACTLY as it appears in your foreign passport)

________________ _________ ______________ _____________

Last Name First Name Middle Name Title (If Candidate of Sciences or Doctor of Sciences)

2. Date of birth / / day/month/year		3. Place of birth city/country
4. Citizenship (Note: You must be a citizen of Ukraine and cannot be a U.S. citizen or Legal Permanent Resident):		5. Foreign passport expiration date_______
6. Institution name /Contact Address Institution Name: Department:		7. Home Address Street, Building number, Apartment
Street, Building number, korpus		City Index
City Index		Home telephone (include city code) Mobile number:_________________________
Work telephone, fax e-mail address:		e-mail address:

8. Your Current Position and Title: __________________________________________________________________

9. Institution and Department: ______________________

10. Work experience, including previous positions and titles. Use additional space if necessary.

Years (From …To)	Institution and Title	Part/Full time position	Responsibilities (including courses taught, number of students, etc)

Education, Academic and Professional Training, including degrees earned and fields of specialization

Institution and City	Degree earned	Year earned	Specialization

12. Additional Professional Training:

13. Active Professional Memberships:

Position	Title	Organization

14. Publications Related to the Institute Theme (up to 10). Please list all titles in English including whether book, chapter, journal article, newspaper article, web article:

Publication Type	Year	Title Publisher

15. Please check which of the following reflects your status:

a) I teach the course(s) which relates directly to the subject of this institute ____________

______________________________________________________________________

b) I teach a course which includes segments on the subject of this institute ____________

______________________________________________________________________

c) I do not teach a course relevant to the Institute subject yet, but I am currently developing a course entitled: __________________________________________________

to be taught (when?) _______________(where?) ________________________

16. Current courses taught:

Course Title	Level of students (Ph.D., Masters, Undergraduate)	Classroom hours per semester	Number of Students	U.S. Studies Content (%)

17. Current Student Advising:

Number of Students Advised Studying U.S. Related Topics	Level of Students (Ph.D., Masters, Undergraduate)	Hours of Advising per Student

18. Previous travel and study or research experience in the U.S:

Dates (From…To)	Purpose of Visit	Program Title	Sponsor

19. Personal Essays. On separate sheets of paper, please write two personal essays (with a limit of 4,500 characters each) on the following topics:

1) First essay: Please discuss your professional responsibilities in greater detail, including research interests, administrative responsibilities (ex. curriculum design) and/or other pertinent information. 2) Second essay: Please discuss how your participation would enhance your personal and professional goals, the current state of U.S. Studies at your institution, or upon the institute. Please also explain how attending this Institute would help you achieve one or more of the following outcomes that could potentially result from your participation in this program: a) updating an existing course you are currently teaching; b) creating a new course; c) creating a new degree program; d) redesigning your university curriculum; e) launching a new professional organization; and f) developing new institutional linkages.

20. English Proficiency Reading: Excellent ~ Good ~ Fair ~

(TOEFL test score or Writing: Excellent ~ Good ~ Fair ~

self evaluation) Speaking: Excellent ~ Good ~ Fair ~

Please indicate whether this is based on a TOEFL test scoreor self-evaluation.