2018 Study of the United States Summer Institute for Scholars
Application Form
Please email completed applications to:
Application deadline: December 28 6:00 PM Tbilisi time, 2017
Personal Information:
1.Family Name / First Name / Patronymic / Title (Dr./Mr./Mrs./Prof.)
(AS IT APPEARS IN YOUR PASSPORT)
2. / 3. / 4.
Date of Birth (MM/DD/YYYY) / City of Birth / Country of Birth
5. / 6.
Country of Residence / Country of Citizenship
7.
Home Address
Cell phone / Home Telephone / E-mail
(NOTE: Please include the telephone code for your city or region.)
8. / Male / Female
9. / Medical, Physical, Dietary or other Personal Considerations:
Professional Information:
10.
Current Position and Title / Department
11.
Institution
Address
City
Telephone/Cell phone / Fax
12. / Work experience, most recent first:
Institution/Employer / Position / Dates of Employment
13. / Education, Academic and Professional Training, most recent first:
Degrees/Fields of Specialization / Institution / Date
14. / Active professional memberships:
15. / Short List of relevant publications (maximum 10 publications). Publications should include the publication year, type of publication, title, and publisher. All foreign titles should be translated into English. To identify the publication type, please choose from among the following options: 1) book; 2) edited volume (as primary or co-editor); 3) book chapter; 4) journal article; 5) newspaper/online article; 6) conference/university/government working paper.
16. / U.S. Travel:
Purpose / Date / USG-funded
Yes No
Yes No
Yes No
Yes No
17. 17. / Family Residing in the United States. Please list any immediate family members who are currently residing in the United States, including city and state:
18. / English Proficiency:
Reading: / Excellent / Good / Fair
Writing: / Excellent / Good / Fair
Speaking / Excellent / Good / Fair
19. Professional responsibilities. Please discuss your professional responsibilities in greater detail, including research interests, administrative responsibilities, (e.g., curriculum design), and/or other pertinent information.
Recent courses taught. Please include: a) course title; b) level of students (PhD, MA,BA); c) classroom hours per semester; d) number of students per class; and e) U.S. Studies content (%).
Current Student Advising – Advising is not the same as teaching. Please indicate the number of students, their level. And hours you spend providing assistance in helping students clarifying personal and career goals, and evaluating progress towards these goals. This section can also include those that supervise PhD and graduate students.
Please include the number of students advised who are studying U.S.-related topics, level of students (PhD, MA, BA, High School), and the number of advising hours.
Other Potential Outcomes – Please select all of the likely potential outcomes that might result from your participation in this institute: 1) update existing course; 2) create new course; 3) create new degree program; 4) redesign university curriculum; 5) redesign national curriculum; 6) new research project; 7) new publication; 8) professional promotion; 9) government or ministry policy; 10) new professional organization; 11) new institutional linkages; 12) raise institutional profile. Please explain each point marked.
20. Personal Essays (Limit 250 words).
Please discuss why you wish to participate in this program. Include how your participation in the Institute will enhance your personal and professional goals and the current state of U.S. Studies in your country. Include how attending this Institute would help you achieve the“Other Potential Outcomes” you have checked above.
Applications without essays will not be considered.