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SUSI 2020 - 6 Institute Scholar Nomination Form
Title of Institute
*
Please Select Institute
American Culture and Values
U.S. Foreign Policy
Journalism and Media
Religious Freedom and Pluralism in the U.S.
Youth, Workforce Development, and Closing the Skills Gap
U.S. Economics and Business
Select the Institute you would like to apply to.
Title of Institute
*
Please Select Institute
American Culture and Values
American Politics and Political Thought
Contemporary American Literature
U.S. Foreign Policy
Journalism and Media
Religious Freedom and Pluralism in the U.S.
Youth, Workforce Development, and Closing the Skills Gap
U.S. Economics and Business
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
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
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
*
Update Existing course
University Curriculum Redesign
New Publication
New Professional Organization
Create New Course
National Curriculum Redesign
Professional Promotion
New Institutional Linkages
Create New Degree Program
New Research Project
Government or Ministry Policy
Raise Institutional Profile
Please Select any likely potential professional outcomes of this program
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
*
Paste link to video here
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.