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+---------------------------------+---+-----------------------------------+
|                                 |   | #                                 |
+---------------------------------+---+-----------------------------------+

# VIETNAMESE STUDENT FULBRIGHT FELLOWSHIP PROGRAM

##### Preliminary Data Form

###### Academic Year 2007-08

***INSTRUCTIONS:***

-   This Preliminary Data Form (PDF) must be submitted by **post mail**.

> Emailed or faxed forms will not be accepted.

-   All sections must be completed.

> Incomplete forms with items left blank will **not** be accepted.

-   Please attach **one** photocopy of all B.A. degree diplomas. Copies
    do not need to be notarized.

-   The form must be **typewritten. Handwritten forms will not be
    accepted.**

-   **The form must be in** English (unless Vietnamese is requested).

-   The form must be **signed** as though you were signing a legal
    document.

-   Forms received after **February 24, 2006, 5:00 p.m.** or with
    missing information or signature will not be considered.

Questions about this form should be directed to Ms. Jessy Needham,
Fulbright Program Officer, at (04) 831-4580 x155 or needhamjc@state.gov.

![](media/image2.png){width="6.489583333333333in"
height="2.0833333333333332e-2in"}

**1. NAME:**      

TiÕng ViÖt cã dÊu: Family (Họ) Middle (Tên đệm) First (Tên)

**2. Male** **or Female** **(check one)**

**3. Do you have Vietnamese single citizenship? Yes** **No** **(check
one)**

(Quốc tịch Việt Nam, không có quốc tịch thứ hai)

**4. DATE OF BIRTH:** (dd/mm/yyyy)      

5.  **MAILING ADDRESS in [VIETNAMESE]{.underline}** (Địa chỉ nhận thư,
    viết [bằng tiếng Việt cã dÊu]{.underline})

>      

**6. Contact Telephone:**      

**7. Email:**       **8. Mobile Phone:**      

**CURRENT EMPLOYMENT INFORMATION:**

**9. Position/Title** (in English and Vietnamese)

>      

10. **Organization/Affiliation** (Cơ quan công tác) (in English and
    Vietnamese)

     

11. **Date joined:** (dd/mm/yy)      

12. **Type of Organization: (check one)**

> State-owned company
>
> Non-state-owned company
>
> University/School
>
> Vietnamese Government
>
> International NGO
>
> Vietnamese NGO \
> Other (please specify)
>
>      

**13. Business/Office Address in Vietnamese (bằng tiếng Việt cã dÊu)**

>      

**Telephone:**       **Fax:**      

14. **Describe, [in English]{.underline}, your responsibilities and your
    organization (limit your answer to [5 lines]{.underline}):**

          

**15. ACADEMIC BACKGROUND:** (begin with highest degree, in English and
Vietnamese)

+-----------+-----------+----------+----------+-----------+----------+
|           | ENGLISH   |          |          | TIẾNG     |          |
|           |           |          |          | VIỆT      |          |
+-----------+-----------+----------+----------+-----------+----------+
| Univer    | Fie       | Date     | Trư      | Chuyên    | Ngày (Từ |
| sity/City | ld/Degree | (MM/YY   | ờng/Tỉnh | ngành/    | T        |
|           |           | to       |          |           | háng/Năm |
|           |           | MM/YY)   |          | Bằng      | đến      |
|           |           |          |          |           | Th       |
|           |           |          |          |           | áng/Năm) |
+-----------+-----------+----------+----------+-----------+----------+
|           |           |          |          |           |          |
+-----------+-----------+----------+----------+-----------+----------+
|           |           |          |          |           |          |
+-----------+-----------+----------+----------+-----------+----------+
|           |           |          |          |           |          |
+-----------+-----------+----------+----------+-----------+----------+

**16. EMPLOYMENT HISTORY:** (begin with current position, in English and
Vietnamese)

+-----------+----------+----------+-----------+-----------+----------+
|           | ENGLISH  |          |           | TIẾNG     |          |
|           |          |          |           | VIỆT      |          |
+-----------+----------+----------+-----------+-----------+----------+
| Position  | Orga     | Date     | Chức vụ   | Tên và    | Ngày (Từ |
|           | nization | (MM/YY   |           |           | T        |
|           | and      | to       |           | địa chỉ   | háng/Năm |
|           | Location | MM/YY)   |           | cơ quan   | đến      |
|           |          |          |           |           | Th       |
|           |          |          |           |           | áng/Năm) |
+-----------+----------+----------+-----------+-----------+----------+
|           |          |          |           |           |          |
+-----------+----------+----------+-----------+-----------+----------+
|           |          |          |           |           |          |
+-----------+----------+----------+-----------+-----------+----------+
|           |          |          |           |           |          |
+-----------+----------+----------+-----------+-----------+----------+
|           |          |          |           |           |          |
+-----------+----------+----------+-----------+-----------+----------+

**17. Have you lived outside Vietnam since 2003?** **Yes** **No**
**(check one)**

**If yes, where, why and for how long?**

     

**18. Which field do you propose to study?**

     

**FULBRIGHT INFORMATION:**

**19. How did you hear about the Fulbright Program?**

Newspaper Internet TV Friends

**20. Have you applied for a Fulbright Fellowship before? Yes** **No**

**Which year?**      

*The Fulbright Program willingly accepts applications from applicants
from previous years.*

I certify that all the information given above is complete and accurate
to the best of my knowledge.

**Signature**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Date**: