SUSI 2019 - 7 Institute Scholar Nomination Form
  • Select the Institute you would like to apply to.
  • Nominee's Full Name, exactly as it appears on candidate's passport
  • Ejemplo: 06/28/1973 / Canelones / Uruguayo / Maldonado
  • Do not use commas, dots or slash.
  • 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.
  • Numbers Only. For example: 23456789 and 09X XXXXXX
  • Name / Relationship / Phone / Email

    Example: John Doe / Husband / 59824002233 / johndoe@email.com
  • 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 / Title / Organization (ie. Director, Board Member, etc.)
  • Please list all foreign titles in English, including whether book, chapter, journal article, web article, etc. 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, Cousin, Chicago, IL)
  • 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.
  • 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)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.
  • Please Select any likely potential professional outcomes of this program
  • 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
  • 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.
  • 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.
Powered byEMF Form Builder
Report Abuse