UNITED STATES-INDIA EDUCATIONAL FOUNDATION

Fulbright House, 12 Hailey oa!, Ne" Delhi 11# ##1

$reli%i&ary A''li(atio& For% )or 2#1*-2#1+ Hubert H, Hu%'hrey Fello"shi' $rogra% A$$LICATION INST UCTIONS 1. Each page of the enclosed application carries its own instructions and should be read carefully before proceeding. All forms must be completed in English and computergenerated. Please answer every question as completely as possible (except for the !ubstance Abuse "ield of !tudy# form$ page % of the application$ which should only be completed by candidates in the field of substance abuse&. '. Please ta(e special notice of )tem *o. 1+$ ,-ive a ./-word summary of your proposed program plan., Please be sure to provide a succinct and substantive summary statement. 0. 1ompleted applications (including enclosures$ if any& must be submitted through the appropriate administrative authority to the 2!)E" office within your region. +. 3ou are required to get two letters of reference$ one of which must be from your immediate supervisor in your current position. 4eferees should send the letters of reference directly to the Executive 5irector$ 2nited !tates-)ndia Educational "oundation$ "ulbright 6ouse$ 1' 6ailey 4oad$ *ew 5elhi 11/ //1 by 7uly 1$ '/1+. .. -ar&i&g. $lagiaris% i& the a''li(atio& "ill lea! to !is/uali)i(atio&, A''li(atio& Dea!li&e. 0uly 1, 2#11

Bio-Sheet A
1. NAME OF APPLICANT (Exactly as on your passport/ travel docu ents! " #. $E%" Fe ale Male

Mr.
(Title)

(First name)

(Middle name)

(Last name)

&. PLACE OF 'I(T) (c*ty or to+n, country!" 7. 1ATE OF 'I(T) Mont2 1ay 8ear

-. C.((ENT PO$ITION, O(/ANI0ATION AN1 A11(E$$" Telep2one nu 3er (*nclude country 4 c*ty codes!" )o e" 5or6" Fax" Cell" E a*l"

9. CO.NT(8 OF P(E$ENT CITI0EN$)IP"

:. MA(ITAL $TAT.$" $*nBle Marr*ed

;. P(EFE((E1 MAILIN/ A11(E$$ (I< sa e as a3ove, +r*te =sa e>!"

?. CO.NT(8 OF P(E$ENT (E$I1ENCE" 1@. IN1ICATE 8EA( 4 CO.NT(8 OF AN8 P(EAIO.$ F.L'(I/)T /(ANT$"

11. E1.CATION" L*st all post-secondary educat*onal *nst*tut*ons attended, 3eB*nn*nB +*t2 t2e ost recent, *nclud*nB any *n +2*c2 you are currently enrolled. Cop*es o< d*plo as, acade *c transcr*pts, cert*<*cates, and EnBl*s2 translat*ons s2ould 3e attac2ed. (To add ore *n<or at*on, please add ro+s or copy ta3le onto an add*t*onal s2eet.! Na e o< *nst*tut*on, un*vers*ty or pro<ess*onal sc2ool, and locat*on a. MaCor <*eld(s! o< study 1ates attended ( ont2 and year! Fro To Actual na e o< d*plo a or deBree (do not translate! 1ate rece*ved or expected

3.

c.

d.

e.

1-. Na e your most significant pu3l*cat*ons/2onors/a+ards/proCects/ot2er acco pl*s2 ents (1o not exceed 1& l*nes o< text!"

1;. F*eld o< $tudy (Please c2oose one! 1#. /IAE A 50-WORD $.MMA(8 OF 8O.( P(OPO$E1 PROGRAM PLA ( ore co plete plan to 3e outl*ned *n Ite (-!D 3e sure t2*s su ary captures t2e essence o< your proBra plan!. (1o not exceed ; l*nes o< text!" No. --

1&. C.((ENT OCC.PATION" 8our Co3 t*tle" 1ates o< e ploy ent ( ont2 4 year!" Na e and address o< your place o< e ploy ent"

17. 1escr*3e your current Co3 respons*3*l*t*es. (1o not exceed & l*nes o< text!"

Bio-Sheet B
19. Prev*ous pos*t*ons 2eld (3eB*n +*t2 ost recent!" Eo3 T*tle 1ates o< E ploy ent Fro To Na e 4 address o< place o< e ploy ent 1. -. ;. #. &. 7.

1:. Please *nd*cate your co puter pro<*c*ency and level o< s6*ll *n +ord process*nB, spreads2eets, electron*c o< 1F&. Please 3e spec*<*c. 5ord Process*nB $preads2eets

a*l, etc. on a scale

EFMa*l

1?. Please *nd*cate countr*es outs*de your o+n, *nclud*nB t2e .n*ted $tates, *n +2*c2 you 2ave l*ved, traveled, or stud*ed. Please l*st dates ( ont2s/years! and reasons <or eac2 v*s*t. Please attac2 an add*t*onal s2eet *< necessary. 1ates o< v*s*t (eason <or v*s*t Country v*s*ted Fro To 1. -. ;. #. &. 7. -@. Persons to 3e not*<*ed *n case o< e erBency" In 2o e country" Na e" Address" Telep2one" (elat*ons2*p In t2e .n*ted $tates (<r*end or <a *ly Na e" Address" Telep2one" (elat*ons2*p" e 3er!"

!"# Dec$aration" I cert*<y t2at all *n<or at*on B*ven *n t2*s appl*cat*on *s co plete and accurate to t2e 3est o< y 6no+ledBe. I ac6no+ledBe t2at I 2ave co pletely read and understood t2e Information and Application Instructions and I aBree to co ply +*t2 all reBulat*ons descr*3ed t2ere. I aBree to a3*de 3y t2e Psol*c*es Bovern*nB t2e select*on o< Ful3r*B2t/)u p2rey Brantees, as esta3l*s2ed 3y t2e E. 5*ll*a Ful3r*B2t Fore*Bn $c2olars2*p 'oard (F$'! (co plete pol*c*es ava*la3le at 2ttp"//eca.state.Bov/<ul3r*B2t/a3outF<ul3r*B2t/CF+*ll*a F<ul3r*B2tF<ore*BnFsc2olars2*pF 3oardF<<s3/<<s3Fpol*c*es! +2*c2 supersedes all ot2er docu ents relat*nB to y appl*cat*on <or a )u p2rey Fello+s2*p. I also aBree to return to y 2o e country upon t2e exp*rat*on o< y proBra *n t2e .n*ted $tates o< A er*ca.
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Program P$an
Na e o< appl*cant" !!# (1! Please descr*3e your country. Country" aCor area o< *nterest and expla*n 2o+ t2*s area addresses t2e spec*<*c develop ent needs o< your

(-! 1escr*3e t2e type o< )u p2rey proBra you +ould l*6e to des*Bn *n order to eet t2ese c2allenBes. Ind*cate t2e 6*nds o< acade *c course +or6, *nterns2*p exper*ences, and/or pro<ess*onal tra*n*nB exper*ences you +ould l*6e to underta6e.

(;! 1escr*3e 2o+ t2e acIu*s*t*on o< ne+ 6no+ledBe and s6*lls +*ll ass*st you *n 2elp*nB your country to ac2*eve *ts develop ent Boals.

Persona$ Statements A
Na e o< Appl*cant" Country" 5r*te a paraBrap2 ans+er*nB eac2 o< t2e <ollo+*nB t2ree Iuest*ons. Please use on$y t2e space prov*ded !%# Please descr*3e 2o+ you 2ave de onstrated a stronB co pro<ess*onal respons*3*l*t*es, etc.! *t ent to pu3l*c serv*ce. (*.e. co un*ty, c*v*c *nvolve ent or

!&# Please state your pro<ess*onal Boals <or t2e next <*ve years and *nd*cate 2o+ t2e tra*n*nB rece*ved under t2e )u p2rey ProBra +*ll contr*3ute to your anaBer*al s6*lls, leaders2*p a3*l*ty, and co *t ent to pu3l*c serv*ce.

Persona$ Statements B
Na e o< Appl*cant" Country" !5# 1escr*3e a pro3le or c2allenB*nB s*tuat*on t2at you 2ave resolved 3y us*nB your *n*t*at*ve. 52at +as t2e outco eJ Please select t2*s exa ple care<ully. It s2ould *llustrate so et2*nB t2at you +ant t2e rev*e+ panel to 6no+ a3out your pro3le Fsolv*nB, leaders2*p a3*l*t*es, or co *t ent to pu3l*c serv*ce.

S'(stance A('se )ie$d of St'dy

-. 'r*e<ly descr*3e recent su3stance a3use researc2 proCect(s! *n +2*c2 you 2ave 3een enBaBed, t2e extent o< your role *n t2ese proCect(s!, and l*st any pu3l*cat*ons *n connect*on +*t2 researc2 +or6 t2at you 2ave done.

;. 'r*e<ly descr*3e an area o< su3stance a3use researc2 t2at you +ould l*6e to pursue 3ased on t2e needs *n your country.

ADDENDUM

-7. +MPLO0+R2S 1OMM+ *S KMust 3e <*lledF*n 3y t2e Ad *n*strat*ve )ead o< t2e *nst*tut*on and not t2e * ed*ate superv*sor or 2ead o< t2e depart entL" Please co ent on t2e use<ulness o< t2e proBra to t2e orBan*Mat*on as +ell as to t2e appl*cant on 2*s/2er return <ro t2e ..$. Please *nd*cate +2et2er t2e appl*cant +*ll rece*ve leave <or t2e per*od o< 2*s/2er Brant, *< selected.

E ployerNs $*Bnature " O<<*c*al $eal" 1ate" Na e 1es*Bnat*on " "

-9. -o3 did yo' $earn a(o't the )'$(right Program4 (Please *nd*cate all t2at apply! Fr*end or relat*ve Prev*ous Ful3r*B2ter Poster/Flyer .n*vers*ty (spec*<y! Ne+spaper (spec*<y! Ot2er Pu3l*cat*on (spec*<y! Ful3r*B2t 5e3s*te Internet L*n6 Ot2er

-:. Attac2 ents reIu*red" a! Please attac2 a 3r*e< resu e.

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Na e and $*Bnature o< t2e Appl*cant