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.