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.

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

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

Please include:
Position (ie. Director, member) / Title / Organization

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

Please indicate Purpose / Dates (from Month, Year to Month, Year) / description

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

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

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

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

Note: Include a) Name of Activity, b) Postition Title (ie. Director, Coach, Manager), c) Dates (from mm/dd/yyyy to mm/dd/yyyy) and a short description of duties.

Please discuss why you wish to participate in this program.

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

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.

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

Note: Do not exceed 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

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.

Submite complete name, cell phone and e-mail address of a reference from your Institution.

Embassy will contact the Working Reference.