EmailMe Form - SUSI 2020 - 6 Institute Scholar Nomination Form

Title of Institute *

Select the Institute you would like to apply to.

Title of Institute *

Select the Institute you would like to apply to.

Name *

Prefix First Last Suffix

Nominee's Full Name, exactly as it appears on candidate's passport

Gender *

Male

Female

Date / Place of Birth / Citizenship / Residency *

Ejemplo: 06/28/1973 / Canelones / Uruguayo / Maldonado

ID Number
(cédula de identidad) *

Do not use commas, dots or slash.

Medical, Physical, Dietary or other Personal Considerations *

Please describe any pre-existing medical conditions, including any prescription medication you may be taking, allergies, or other dietary or personal consideration.

This will not affect candidate selection, but will enable the host institution to make any necessary accommodations.

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Phone and Cell Phone *

Numbers Only. For example: 23456789 and 09X XXXXXX

Emergency Contact *

Name / Relationship / Phone / Email

Example: John Doe / Husband / 59824002233 / johndoe@email.com

Current Position *

Senior University Official (President, Provost), Government Minister, Senior Executive)

University Dean, Government Advisor, Vice President, Junior Executive

Senior Professor, Department Chair, Director, Editor, Officer, etc.

Associate Professor, Senior Researcher / Think Tank Fellow, Senior Staff, etc.

Assistant Professor, Assistant Editor, Coordinator, mid-level Staff Researcher / Think Tank Fellow, etc.

Lecturer, Teacher, Consultant

Teaching Assistant, Instructor

Other

Your Job Title / University Name / Country *

Work experience, including previous position and job titles. *

Note: Include dates (from mm/dd/yyyy - to mm/dd/yyyy), Title / Institution AND specify if position is part-time.

Education, Academic and Professional Training *

Please list all earned degrees beginning with most recent. Degrees listed should reflect the closest U.S. equivalent

Please include:
Degree earned / Year earned / Specialization / Institution

And include Additional Professional Training

Active Professional Memberships *

Active Professional Memberships independent of current professional responsibilities. These should not include university committee work or other professional duties directly related to current employment

Please include:
Position / Title / Organization (ie. Director, Board Member, etc.)

Publications Related to the Institute Theme (up to 10) *

Please list all foreign titles in English, including whether book, chapter, journal article, web article, etc. with date (mm/dd/yyyy) and Publisher.

Previous experience in the United States *

Please indicate Purpose / Dates (From Month, year to Month, year) / description

Family / Friends Residing in the United States *

Please include name, relationship, city and state (Example: John Doe, Cousin, Chicago, IL)

Evidence of English Fluency *

Please comment on your level of English; where you studied, if you have internatinal exams, etc.

Professional Responsibilities *

Discuss your professional responsibilities with greater detail, including research interests, administrative responsibilities (ie. curriculum design) and/or other pertinent information.

Current Courses Taught *

Note: Include a) Course Title, b) Level of Students, c) Classroom Hours per Semester, d) Number of Students, e) U.S. Studies Content (in %)

Current Student Advising *

Note: Include a)Number of students advised studying U.S. related topics, b) Level of Students, c) Hours advising per student per year

Advising is not the same as teaching. we are looking for the number of students, their level, and hours the nominee spends providing assistance in helping students clarifying personal and career goals, and evaluating progress towards those goals. This section can include those that supervise PhD and graduate students.

Other Potential Outcomes *

Personal Essay

Limit: 210 words *

Please discuss how your participation would enhance your personal and professional goals, the current state of U.S. studies in your home country, or upon the Institute.

What you expect to gain and what you will contribute to the Institute.

Include how attending this Institute would help you achieve the "Other Potential Outcomes" you have checked above.

Please also describe your capacity to amplify the impact of this program.

Note: Do not exceed 210 words

Justification of Participation

Limit: 210 words *

Please discuss why we should nominate you and how your participation fits into your Institution's current efforts to promote a greater understanding of the United States.

How would you share the experience?

Include any long term relationship you could think of between you or your Institution and the U.S. Embassy in the future.

Limit: 210 words

Working Reference *

Please include complete name, cell phone number and e-mail address of a professional reference from your institution.

Embassy will contact your Working Reference.

One Minute Video *

Please discuss why you wish to participate in this program. Include how your participation in the Institute will enhance your work, improve education about the United States in your community, and help you achieve the "Other potential Outcomes" you have checked above.
Be creative!

Note: Longer videos will not be considered. Make sure your video is accessible or it will not be considered.