FULBRIGHT
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FOREIGN FULBRIGHT GRANT APPLICATION COVER SHEET
Name:
Family
First Middle
PERMANENT ADDRESS:
EMAIL ADDRESS:
COUNTRY OF CURRENT CITIZENSHIP
COUNTRY OF BIRTH DATE OF BIRTH / /
GENDER:
CURRENT OCCUPATION
MOST RECENT EMPLOYER:
FROM / TO /
ACADEMIC DEGREES
Degree Field of Study
SCHOLARSHIPS
TEACHING EXPERIENCE:
If you currently or previously held a language teaching position, please estimate how long you occupied the post.
Years Months Not Applicable
LANGUAGE SKILLS:
What language are you applying to teach/assist in the U.S.?
Plagiarism Agreement
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FULBRIGHT PROGRAM
Application for foreign language teaching assistantship in the United States
General Information
1. APPLICANT NAME SUBMISSION: The first, middle and last (family) name provided on this application should be spelled exactly as it appears in your passport. If you do not have a passport, you should submit the first, middle and last name spelling that would likely appear on your passport.
Do you currently have a passport?
2. NAME (As it appears or will appear on your passport)
Last (Family) First Middle
Address all inquires about this candidate to: 3. PERMANENT MAILING ADDRESS:
Street
Institute of International Education
Fulbright Foreign Language Teaching Assistant (FLTA) Program
809 United Nations Plaza
New York, NY 1001
E-mail: FLTA@
City State (USA) State/Province
Postal Code (outside USA)
Country
Telephone:
( )
E-mail:
4. DATE OF BIRTH: (Month/Day/Year) / / 5. CURRENT AGE
6. GENDER
8. COUNTRY OF CITIZENSHIP
7. BIRTHPLACE: (City, State/Province, Country)
State (if USA)
9. COUNTRY OF RESIDENCE
State/Province (outside USA)
10. DO YOU NOW HAVE, OR HAVE YOU EVER HELD:
U.S. CITIZENSHIP?
U.S. DUAL CITIZENSHIP?
U.S. PERMANENT RESIDENCY?
DO YOU HAVE A VISA LOTTERY APPLICATION PENDING?
HAVE YOU EVER APPLIED FOR
U.S. PERMANENT RESIDENCY (i.e. green card)? My application was denied
My application is still pending
PLEASE SELECT ONLY ONE OF THE FOLLOWING REGARDING YOUR POSSIBLE ROLE ON A U.S. UNIVERSITY CAMPUS
11. IN YOUR ROLE AS A LANGUAGE ASSISTANT ON A U.S. UNIVERSITY CAMPUS, YOU ARE WILLING TO:
12. IS THERE A PARTICULAR REGION IN THE U.S. THAT INTERESTS YOU?
13.
IF THERE IS A SPECIFIC REGION THAT INTERESTS YOU, PLEASE INDICATE IT HERE. IF THERE IS NOT A SPECIFIC REGION, PLEASE INSERT N/A. (APPLICANTS ARE NOT GUARANTEED PLACEMENT IN THE REGION INDICATED.)
14. IS THERE ANY COLLEGE OR UNIVERSITY TYPE FROM WHICH YOU WOULD REFUSE AN OFFER ASSISTANTSHIP?
Single gender student body
Rural location Large population
Great ethnic diversity
Requires specific coursework on a credit basis
Urban location
Small population
Little ethnic diversity
Offers coursework on an audit basis
N/A, I would accept all
Fulbright FLTA Program Application
Plagiarism Agreement
The FLTA Program seeks applicants that have developed a sense of personal integrity and are original thinkers. The following application includes several opportunities to express your own thoughts, ideas, and opinions in essay responses. Plagiarism in any of your answers to these questions will result in your disqualification from participating in the FLTA program.
From the Oxford English Dictionary:
"Plagiarism is the wrongful appropriation or purloining and publication as one's own, of the ideas, or the expression of the ideas of another"
Plagiarism will be understood to include any of the following:
Presenting wording, statistics or concepts as your own which should be attributed to someone else or to publications
(online or offline). This includes, but is not limited to:
o Copying the exact wording of a written source
o Presenting material with alterations in wording
o Paraphrasing the content of a source without citation
It is expected that your responses to essay questions in the following application will be your own work, and that use of outside sources will be kept to a minimum. Applicants do not have to use secondary sources for essays. However, any sources used in the construction of your responses must be cited.
By checking the box below, you are indicating that you understand both what actions constitute plagiarism in this application, and the consequences resulting from any plagiarism found in your submission.
I have reviewed and understand the above information on the importance of presenting my own original work in the Fulbright FLTA program application. I agree to properly cite any outside sources from which I take words or ideas in the composition of my essay responses. I understand the consequences of plagiarism in my FLTA application.
FULBRIGHT
16. ACADEMIC INTERESTS: The FLTA Program is a non-degree program which offers coursework for enrichment purposes. Select 2-3 areas of academic study that you feel would contribute to your development as a language professional. Please note: the subjects you indicate are not guaranteed should you be selected for the FLTA Program. Topics you select give you an opportunity to express your academic interests.
1.
2.
Other
17. NON-ACADEMIC INTERESTS: PLEASE LIST ANY NON-ACADEMIC INTERESTS (e.g. SPORTS, MUSIC, ART, ETC.). INCLUDE INFORMATION ABOUT YOUR EXPERIENCE IN THESE AREAS.
18. ARE YOU PURSUING ANY OTHER SCHOLARSHIP, FELLOWSHIP OR EMPLOYMENT THAT WOULD SUPERCEDE YOUR PARTICIPATION IN THE FLTA PROGRAM SHOULD IT BE OFFERED? PLEASE EXPLAIN:
19. DEGREE: PLEASE INDICATE THE LAST DEGREE YOU COMPLETED. PLEASE DO NOT LIST CERTIFICATES IN THIS SECTION.
|Degree Name (Masters, Bachelors) |Field of Study |
| | |
20. EDUCATION: LIST EDUCATIONAL INSTITUTIONS ATTENDED IN REVERSE CHRONOLOGICAL ORDER, INCLUDING ANY IN WHICH YOU MAY BE PRESENTLY ENROLLED.
|Name of Institution/Location |Major Field of Study |Dates (Month and year) From |Degree or |Date Received or |
| | |To |Diploma Name |Expected |
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21. LIST SCHOLARSHIPS OR FELLOWSHIPS HELD AT PRESENT OR IN THE PAST. GIVE SOURCE OR SPONSOR, AMOUNT, WHERE HELD, DURATION, AND YEAR.
22. INDICATE ACADEMIC HONORS OR PRIZES WHICH YOU HAVE RECEIVED.
23. OCCUPATIONAL EXPERIENCE:
IDENTIFY YOUR CURRENT POSITION OR OCCUPATION (Select the position title which best describes the activity
in which you are currently involved.)
If you selected Teacher as occupation, please specify the subject(s) you teach:
LIST POSITIONS HELD (begin with most recent employment, if any.)
Name and address of Employer Type of Work (Position Held) Reason for leaving
Dates
| | | | |
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24. TEACHING EXPERIENCE: IF YOU CURRENTLY OR PREVIOUSLY HELD A LANGUAGE TEACHING POSITION, PLEASE ESTIMATE HOW LONG YOU OCCUPIED THE POST.
Years
Months
Not Applicable
25. LIST PROFESSIONAL SOCIETIES, FRATERNITIES, OR OTHER ORGANIZATIONS IN WHICH YOU NOW HOLD MEMBERSHIP OR IN WHICH YOU HAVE BEEN ACTIVE IN THE PAST Indicate if you have held an elective office.
26. IF YOU HAVE TRAVELED OR LIVED IN ANY COUNTRY OTHER THAN YOUR OWN, INDICATE PLACES, DATES, AND REASONS.
27. LANGUAGE SKILLS: Please respond to all of the following fields.
What language are you applying to teach/assist in the U.S.?
Category Name of Language Proficient (Skill Level)
Host Country Language:
Mother Tongue:
Second Language:
Third Language:
28. Examination Results:
Name of Exam
TOEFL
IELTS
Date Taken/To be Taken
/
/
Score
Other Test Taken
Date Taken/To be Taken
/
Score
29. Provide the name, address, and telephone number of individuals to be notified in case of emergency.
In Your Home Country In The United States
Family First Street
City
Family First Street
City
State/Province Postal Code
State Postal Code
Country
Telephone ( )
Country
Telephone ( )
Email Email
List Below any close relatives or friends in the United States (name, address, and relationship)
Family First Street
City
Family First Street
City
State Postal Code
State Postal Code
Country
Telephone ( )
Country
Telephone ( )
Email
Email
Relationship Relationship
FULBRIGHT
30. TEACHING THE LANGUAGE OF NOMINATION: You may be asked to teach your own class. If so, what teaching methodologies and techniques would you utilize to teach your language to U.S. students? This brief essay should focus on the language you will be teaching in the U.S. (not English). Mention any innovative approaches you have utilized as a teacher or encountered as a learner that you may employ.
FULBRIGHT
31. SHARING YOUR CULTURE: As a Fulbright FLTA you will act as a cultural ambassador of your country. What do you think it means to be a cultural ambassador? Elaborate on your answer by selecting one of these scenarios and explaining how you would share your culture. 1) A guest lecture at your host institution 2) An international festival3) Volunteering at a local youth center. Please do not insert your actual CV or resume in this section.
This short essay should be your own unique ideas. It is recommended you keep quotations and the use of outside sources to a minimum. However, if you decide to use quotes or information from an outside source, you must include a citation for each one utilized (this refers to websites as well).
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Name: Country:
MARITAL STATUS:
Do you have dependents (individuals for whom you are financially responsible)? : If you answered yes to dependents, how are they related to you (child, mother, father, spouse, etc.)?
Please note, the Fulbright FLTA Program does not provide J-2 visa sponsorship for dependents. Will you be able to participate in the program without dependents? :
PLEASE DESCRIBE ANY PHYSICAL IMPAIRMENT YOU MAY HAVE. (This information is gathered for statistical purposes and to ensure appropriate placement. The Fulbright Program does not discriminate on the basis of race, color, religion, sex, national origin, and/or physical impairment):
The Fulbright provided Accident and Sickness Program for Exchanges (ASPE) health benefit plan does not cover pre-existing conditions. If you have a medical condition, you are encouraged to consult with your physician about how to manage care while in the U.S. and to consider purchasing an international insurance plan.
HAVE YOU PARTICIPATED IN ANY OF THE U.S. GOVERNMENT SPONSORED PROGRAMS LISTED BELOW?
English Access Micro Scholarship
Global Undergraduate Scholarship (UGRAD)
Kennedy-Lugar Youth Exchange & Study Program (YES) Future Leaders Exchange Program (FLEX)
Study of the US Summer Institute
Summer Institute for Young Leaders
Fulbright Student Program Muskie Fellowship Humphrey Fellowship
Undergraduate Intensive English Language Scholarship
Timor or South Pacific Scholarship
Other, specify:
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|Biographic Information Sheet |
|Firs Name: |
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|Date of Birth (e.g. February 10, 2012): |
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|Postal Address: |
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|Permanent Address: |
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|Permanent City: |
|Province: |
|Phone #: |
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|Mobil #: |
|Email ID: |
|Pakistani National (Yes/No): |
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|Academic Information |
|Proposed Field of Study: |
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|Current Enrollment: |
|Start Date: (mm/yyyy) |
|End Date: (mm/yyyy) |
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|Current Field of Study: |
|Current Institution: |
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|Current Degree CGPA/ %age: |
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|Last Degree: |
|Start Date: (mm/yyyy) |
|End Date: (mm/yyyy) |
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|Last Field of Study: |
|Last Institution: |
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|Work Information |
|Current Position: |
|Current Employer: |
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|Total Years of Work Experience: |
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CONFIDENTIAL LETTER OF REFERENCE
This letter of reference must be written by a teacher under whom the applicant has studied or by someone who has supervised the applicant in work, athletics or other relevant activity. This letter must be in English. If not in English, then an accurate translation must be attached.
Name of Applicant _________________________________Country _________________________
Name of Referee __________________________________________________________________________________
1. How long have you known the applicant?
2. In what capacity have you known the applicant?
Teacher or Professor θ Employer or Job Supervisor θ
School Counselor θ Other (please specify) ____________
3. Please provide a candid evaluation of the applicant’s past performance and ability to pursue and successfully complete a teaching assistantship in the United States. Your statement will be given considerable importance by the American universities/colleges reviewing this application, and should, therefore, be as complete and detailed as possible.
CONFIDENTIAL LETTER OF REFERENCE FOR ____________________________________________(continued)
4. In the rating chart below please evaluate the applicant in comparison with other students whom you have known during your professional career.
| |Excellent |Very Good |Average |Below Average |
|Creative | | | | |
|Motivation | | | | |
|Self-confidence | | | | |
|Independence, initiative | | | | |
|Intellectual ability | | | | |
|Academic achievement | | | | |
|Disciplined work habits | | | | |
|Adaptability to New Situations | | | | |
|Leadership Qualities | | | | |
|Potential for growth | | | | |
5.Please indicate where the applicant would rank among students/employees currently or recently in your department/organization.
95% 90% 75% 50% 25%
TOP BOTTOM
__________________________________________________________________________________________________
Name and Title (print) __________________________________________________________________________________________________
School, Company or Organization __________________________________________________________________________________________________
Signature ________________________________________ Date ________________________________
Please return directly to the Selection Committee in the applicant’s home country. Under no circumstances should the completed form be returned to the applicant.
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CONFIDENTIAL LETTER OF REFERENCE
This letter of reference must be written by a teacher under whom the applicant has studied or by someone who has supervised the applicant in work, athletics or other relevant activity. This letter must be in English. If not in English, then an accurate translation must be attached.
Name of Applicant ________________________________Country __________________________
Name of Referee __________________________________________________________________________________
1. How long have you known the applicant?
2. In what capacity have you known the applicant?
Teacher or Professor θ Employer or Job Supervisor θ
School Counselor θ Other (please specify) ____________
3. Please provide a candid evaluation of the applicant’s past performance and ability to pursue and successfully complete a teaching assistantship in the United States. Your statement will be given considerable importance by the American universities/colleges reviewing this application, and should, therefore, be as complete and detailed as possible.
CONFIDENTIAL LETTER OF REFERENCE FOR____________________________(continued)
4. In the rating chart below please evaluate the applicant in comparison with other students whom you have known during your professional career.
| |Excellent |Very Good |Average |Below Average |
|Creative | | | | |
|Motivation | | | | |
|Self-confidence | | | | |
|Independence, initiative | | | | |
|Intellectual ability | | | | |
|Academic achievement | | | | |
|Disciplined work habits | | | | |
|Adaptability to New Situations | | | | |
|Leadership Qualities | | | | |
|Potential for growth | | | | |
5.Please indicate where the applicant would rank among students/employees currently or recently in your department/organization.
95% 90% 75% 50% 25%
TOP BOTTOM
__________________________________________________________________________________________________
Name and Title (print) __________________________________________________________________________________________________
School, Company or Organization __________________________________________________________________________________________________
Signature ________________________________________ Date ________________________________
Please return directly to the Selection Committee in the applicant’s home country. Under no circumstances should the completed form be returned to the applicant.
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CONFIDENTIAL LETTER OF REFERENCE
This letter of reference must be written by a teacher under whom the applicant has studied or by someone who has supervised the applicant in work, athletics or other relevant activity. This letter must be in English. If not in English, then an accurate translation must be attached.
Name of Applicant ____________________________Country _______________________________
Name of Referee __________________________________________________________________________________
1. How long have you known the applicant?
2. In what capacity have you known the applicant?
Teacher or Professor θ Employer or Job Supervisor θ
School Counselor θ Other (please specify) ____________
3. Please provide a candid evaluation of the applicant’s past performance and ability to pursue and successfully complete a teaching assistantship in the United States. Your statement will be given considerable importance by the American universities/colleges reviewing this application, and should, therefore, be as complete and detailed as possible.
CONFIDENTIAL LETTER OF REFERENCE FOR ______________________________(continued)
4. In the rating chart below please evaluate the applicant in comparison with other students whom you have known during your professional career.
| |Excellent |Very Good |Average |Below Average |
|Creative | | | | |
|Motivation | | | | |
|Self-confidence | | | | |
|Independence, initiative | | | | |
|Intellectual ability | | | | |
|Academic achievement | | | | |
|Disciplined work habits | | | | |
|Adaptability to New Situations | | | | |
|Leadership Qualities | | | | |
|Potential for growth | | | | |
5.Please indicate where the applicant would rank among students/employees currently or recently in your department/organization.
95% 90% 75% 50% 25%
TOP BOTTOM
__________________________________________________________________________________________________
Name and Title (print) __________________________________________________________________________________________________
School, Company or Organization __________________________________________________________________________________________________
Signature ________________________________________ Date ________________________________
Please return directly to the Selection Committee in the applicant’s home country. Under no circumstances should the completed form be returned to the applicant.
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Long Essays: Should not exceed two typed pages.
Objectives: Item 15 is one of two long essays you must complete for your application.
Completing the Objectives essay provides the readers (your home country contact, FLTA Program staff and your future supervisor and other university/college officials) with a picture of you and your career interests. This essay will allow you to:
• Emphasize key qualifications, areas of expertise, skills and/or goals
Tip: Reflect on your overall qualifications and career goals: In what ways do they fit with the FLTA Program?
• Help the readers find out about your character/personality
Tip: Think about making a good first impression
• Appeal to college/university supervisor expectations
Tip: Consider: What qualifications are most desired by college and university professors in a language teacher/assistant? What other personal qualities do you possess that would make you attractive to them? Think about what role--or roles— you expect to have on campus?
A good essay for this task will answer these questions:
1. Why are you applying for the FLTA Program?
2. What are your main qualifications?
3. What are your career goals?
Item 32 – Personal Statement: You should not copy your Objectives statement to this section. You should create a new essay. You may include your curriculum vitae or resume. This essay will allow you to:
• Tell a story
Tip: Consider: What’s special, unique, distinctive and impressive about your life story?
• Present your life experience
Tip: Consider: Why might you be a better and more successful FLTA than others?
• Help your future supervisor get to know you as a person
Tip: Consider: What personal characteristics do you possess?
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1.
2.
Other
25.
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AUTHORIZATION OF RELEASE OF INFORMATION:
I authorize the Fulbright Program Office or its administrative agency:
1) to receive and/or request my TOEFL, TSE, TWE or any other test score reports;
2) to send any of the above score reports to U.S. institutions on my behalf;
3) to use my photo image for purposes relevant to program display and promotion.
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FULBRIGHT
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