EmailMe Form - Study of the U.S. Institutes (SUSI)

Select the SUSI Institute *

SUSI for Scholars

SUSI for Secondary Educators

- If You Selected SUSI for Secondary Educators

Select the Theme of the SUSI Institute.

- If You Selected SUSI for Scholars

Select the Theme of the SUSI Institute.

SECTION A: CANDIDATE INFORMATION

Please provide information exactly as it appears in the candidate's passport.

Name *

First MI Last

UPLOAD - Scanned copy of your ID (Cédula) *

Scan your ID (cédula) and upload it here using any of these formats: PDF, PNG or JPG. File size limit: 2MB.

Gender *

Female

Male

Non-binary / No answer

Date of Birth *

MM / DD / YYYY

City of Birth *

Country of Birth *

Citizenship

Please fill as appropriate

Primary Citizenship *

Country of Residence *

Secondary Citizenship (If aplicable)

Candidate Contact Information

Please fill as appropriate

Address *

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

Cell Phone Number *

Confirm

Other Phone Number *

Confirm

Email

Confirm

Medical, Physical, Dietary, or other Personal Considerations

This will not affect a candidate's selection, but will enable the host institution to make any necessary accommodations. Please indicate if the candidate has a disability.

Please indicate if the candidate has a disability *

If other, please specify

Please describe any pre-existing medical conditions, including any prescription medication required, dietary restrictions, or personal considerations

Experience in the United States

Has the applicant traveled to the United States before? *

Yes

No

If yes, please list any previous travel to the United States

Please list any previous travel to the United States for the purposes of tourism/vacation, conferences, educational study, or previous ECA related grants. Provide dates/duration, purpose of visit(s), and location. (Example: July 4-14, 2019 Tourism to Washington, D.C.; December 1-15 2018, Short Term Study Abroad to New York City, NY.)

Family Residing in the United States (if applicable)

Please include relation information, city, and state. (Example: Jane Doe, sister- Denver, CO)

SECTION B: CANDIDATE BACKGROUND

Education *

Please list all earned degrees beginning with the most recent. Each entry should include the following information:

-Degree Earned (Degrees should reflect the closest U.S. equivalent.)
-Year Awarded
-Specialization
-Institution

Additional Academic/Professional Training/ Workshops *

Please list all Additional Academic/Professional Training/ Workshops

Current Role/Job Title *

Please fill

Institution/Organization Name *

Please fill

Institution/Organization Country

Work History *

Please limit work experience to the FIVE most recent job positions
Please provide the following information for each entry:
-Institution
-Dates of Employment (Month/Year-Month/Year)
-Title/Position (please specify if part-time)

Professional Responsibilities *

Nominees should discuss professional responsibilities in greater detail, including research interests, administrative responsibilities (example: curriculum design), and/or other pertinent information not included in the section above.

Current Courses Taught *

If the candidate is not currently teaching courses, please indicate NOT APPLICABLE. Please include all the following information for each course:
-Course Title
-Indicate Level of Students (Secondary School Students/Undergraduate Students/Graduate Students)
-Classroom Hours per Semester
-Number of Students
-% of U.S. Studies Content

Current Student Advising

Advising is not the same as teaching. If the candidate advises students please input the number of students, their level, and hours the candidate spends providing assistance in helping students clarifying personal and career goals, and evaluating progress towards those goals. This section can also include those that supervise Ph.D. and graduate students.

Please include all the following information:
-Number of Students Advised Studying U.S. Related Topics
-Indicate Level of Students (Secondary School Students/Undergraduate Students/Graduate Students)
-Hours of Advising Per Student Per Year

Publications Related to the Institute Theme

Please list all foreign titles in English, including whether the publication was a book, chapter, journal article, newspaper article, etc. Please only list publications within the last five years.

Active Memberships in Professional Associations

Please limit to three most relevant. Provide the position and organization. (Example: President, Washington Educational Professionals Association.)

Other Leadership Positions Beyond Professional Duties

Please provide the activity, position/title, year started, year completed, and the description of duties.

Potential Outcomes *

Candidate Personal Statement *

As part of the SUSI application process, candidates should submit a personal statement about their background and goals. In up to 300 words, the candidate should address the following questions and any other pertinent information:

Why are you interested in participating in the Institute? What do you hope to gain from the Institute?
What will you contribute to the Institute?
How will you leverage the experience to achieve "other potential outcomes" checked in the above section?
How will you amplify the impact of the program beyond your research and knowledge?

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 your experience?

Include any sort of long term collaboration you can anticipate between you/your Organization and the U.S. Embassy in the future.

Note: Do not exceed 210 words

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.