SUSI 2019 - 7 Institute Scholar Nomination Form
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
Select the Institute you would like to apply to.
Nominee's Full Name, exactly as it appears on candidate's passport
Date / Place of Birth / Citizenship / Residency
Ejemplo: 06/28/1973 / Canelones / Uruguayo / Maldonado
(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 Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Trinidad and Tobago
Bosnia and Herzegovina
United Arab Emirates
Papua New Guinea
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Sao Tome and Principe
United Republic of Tanzania
Country / Region
Phone and Cell Phone
Numbers Only. For example: 23456789 and 09X XXXXXX
Name / Relationship / Phone / Email
Example: John Doe / Husband / 59824002233 / email@example.com
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
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
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
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.
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 Professional Organization
Create New Course
National Curriculum Redesign
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
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
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.
Note: Longer videos will not be considered. Make sure your video is accessible or it will not be considered.