ACADEMIC PROGRAM
PRELIMINARY APPLICATION FORM
(Must be typewritten)

1. Type of Grant (check one):      Fulbright            Humphrey

2. Title (check one):                               Dr.___   Mr.___  Mrs.___   Ms.___
3. Name: _______________________________________________________________________
                        Family name                              First                              Middle
4. Current position and starting date:
    
     Department/office, institution (complete mailing address, telephone, fax, and e-mail):

5. Country (ies) of citizenship: _____________________________________________________________

6. Date of birth (month/day/year): _________and place of birth___________________
(city/country): _________________________

7. Gender:         Male     Female

8. Academic credentials (degrees-list highest degree earned first, disciplines, dates, and institutions):

 

 

 

 

 

9. Most significant professional accomplishments, major publications, honors, and awards:

 

 

 

10. Proposed project title:

 

11. Abstract or summary of proposal.  In one paragraph state what you wish to do in the United States:

 

 

 

 

 

 

 

 

 

 

 

12. English proficiency (excellent, good, or fair):

Reading:

Writing:

Speaking:                       

13. Marital status:          Married             Single

 

14. Physical impairment (please describe any)

 

 

15. Professional travel and/or residence abroad during the last 5 years (countries, dates, and purpose of activity):

 

 

 

 

 

 

16. Cultural, educational, and professional societies of which you are a member:

 

 

 

 

17. Field for which you are applying for a Humphrey Fellowship (choose one):
Resources and environmental management; public policy analysis and public administration; economic development; agricultural development/agricultural economics; finance and banking; human resource management; urban and regional planning; public health policy and management; technology policy and management; educational planning, administration and curriculum development; communications/journalism; drug abuse education, treatment and prevention; HIV/AIDS policy and prevention; nonproliferation; teaching of English as a foreign language; trafficking of persons; and law and human rights.