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.