Study of the U.S.
Institutes (SUSI)
for Scholars Application Form
* Required
1. Select the Theme of the SUSI Institute (Scholars): *
U.S. Culture, Identity, and Society
Journalism and Media
American Politics and Political Thought
U.S. Economics and Sustainable Development
U.S. Foreign Policy
Contemporary American Literature
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SECTION A: CANDIDATE INFORMATION
Please provide information exactly as it appears in your passport.
2. Title (Dr./Mr./Mrs./Prof.): *
3. Surname (Last Name): *
4. Given Name(s): *
5. Gender: *
Female
Male
Non-binary
Other
6. Date of Birth: *
Format M/D/YYYY
7. City of Birth: *
8. Country of Birth: *
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Citizenship:
9. Primary Citizenship: *
10. Country of Residence: *
11. Secondary Citizenship (if applicable):
Candidate Contact Information:
12. Street Address: *
13. City: *
14. State/Province: *
15. Postal Code:
16. Country: *
17. Phone Number: *
18. Email Address: *
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Medical, Physical, Dietary, or other Personal Considerations:
This will not affect your selection but will enable the host institution to make any necessary accommodations.
19. Please indicate if you have a disability. *
None
Blind or Visual Impairments
Deaf or Hearing Impairments
Learning Disability
Physical Disability
Psychiatric Disability
Systemic Disability
Other
20. Please describe any pre-existing medical conditions, including any prescription medication
required, dietary restrictions, or personal considerations. *
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Experience in the United States:
21. Have you traveled to the United States before? *
Yes
No
22. If yes, please list any previous travel to the United States for the purposes of
tourism/vacation, conferences, educational study, or previous ECA related grants. Provide
dates/duration, purpose of visit(s), and location. (Example: July 4-14, 2019 Tourism to
Washington, D.C.; December 1-15 2018, Short Term Study Abroad to New York City, NY.)
Date Purpose Location
23. Have you previously participated in or been accepted into a U.S. Department of State
sponsored program? This includes both in person and virtual programs. *
Yes
No
24. If Yes, please provide the name of the program and the dates. *
25. Family Residing in the United States (if applicable):
Please include relation information, city, and state. (Example: Jane Doe, sister- Denver, CO)
Name Relationship City, State
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SECTION B: CANDIDATE BACKGROUND
26. Education: *
Please list all earned degrees beginning with the most recent.
Each entry should include the following information:
• Degree Earned (B.A., M.S., LLM, PhD, etc.)
• Year Awarded
• Specialization
• Institution
(Example: Master's; 2019; International Relations; American University)
Degree Year Awarded Specialization Institution
27. Additional Academic/Professional Training/ Workshops: *
28. Current Role/Job Title: *
29. Institution/Organization Name: *
30. Institution/Organization Country: *
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31. Work History: *
Please limit work experience to the FIVE most recent job positions. Please provide the following
information for each entry:
• Institution
• Dates of Employment (Month/Year-Month/Year)
• Title/Position (please specify if part-time)
(Ex. American University; 01/2019-01/2020; Professor of International Relations)
Institution/Employer Dates of Employment Title/Position
(mm/yyyy to mm/yyyy)
32. Professional Responsibilities: *
Discuss professional responsibilities in greater detail, including research interests, administrative
responsibilities (example: curriculum design), and/or other pertinent information not included in the
section above.
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33. Current Courses Taught: *
If you are not currently teaching courses, please indicate NOT APPLICABLE.
Please include the following information for each course:
• Course Title
• Indicate Level of Students (Secondary School Students/Undergraduate Students/Graduate Students)
• Classroom Hours per Semester
• Number of Students
• Percent of U.S. Studies Content
Course title:
Level of Students:
Classroom hours per
semester:
Number of Students:
US studies Content (%):
Course title:
Level of Students:
Classroom hours per
semester:
Number of Students:
US studies Content (%):
Course title:
Level of Students:
Classroom hours per
semester:
Number of Students:
US studies Content (%):
Course title:
Level of Students:
Classroom hours per
semester:
Number of Students:
US studies Content (%):
Course title:
Level of Students:
Classroom hours per
semester:
Number of Students:
US studies Content (%):
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34. Current Student Advising:
Advising is not the same as teaching. If you advise students please input the number of students, their
level, and hours you spend providing assistance in helping students clarifying personal and career goals
and evaluating progress towards those goals. This section also applies if you supervise Ph.D. and graduate
students. If you are not advising, write NOT APPLICABLE.
Please include the following information:
• Number of Students Advised Studying U.S. Related Topics
• Indicate Level of Students (Secondary School Students/Undergraduate Students/Graduate Students)
• Hours of Advising Per Student Per Year
35. Publications Related to the Institute Theme:
List your publications in citation style. Please list all titles in English, including whether the publication was
a book, chapter, journal article, newspaper article, etc. Please only list publications within the last five
years.
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36. Active Memberships in Professional Associations:
Please limit to three most relevant. Provide the position and organization. Do not use acronyms—write
out the name of the organization.
(Example: President, Washington Educational Professionals Association.)
37. Other Leadership Positions Beyond Professional Duties:
Please provide the activity, position/title, year started, year completed, and the description of duties.
38. Evaluate your English language proficiency. For each domain of language, state whether
you have a novice, intermediate, fluent, or native level of proficiency.
Reading:
Writing:
Speaking:
How long have you studied English? Where/when did you study English?
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39. Potential Outcomes: *
Please select any likely potential professional outcomes of this program:
Create New Course
Create New Degree Program
School Curriculum Redesign
National Curriculum Redesign
New Research Project
New Publication
Professional Promotion
Government or Ministry Policy
New Professional Organization
New Institutional Linkages
Raise Institutional Profile Other
40. Candidate Personal Statement: *
Please submit a personal statement about your background and goals. In up to 500 words, address the
following questions and any other pertinent information:
• Why are you interested in participating in the Institute?
• What do you hope to gain from the Institute?
• What will you contribute to the Institute?
• How will you leverage the experience to achieve "other potential outcomes" checked in the above
section?
• How will you amplify the impact of the program beyond your research and knowledge?
Please input your personal statement below.
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