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**The American Center**

**The Embassy of The United States of America**

Momenshahi House

House \# 110, Road \# 27, Banani, Dhaka-1213

# Tel: 883 7150 - 4, Fax: 9881677, E-mail: DhakaPA@state.gov

## Pre-Application for the Hubert H. Humphrey Fellowship Program

***(Please type or write in block letters)***

1\. Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Date of Birth \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 3. Place
of Birth \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Current official designation and name of office
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5\. Past
Positions\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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6\. List in chronological order all academic institutions you have
attended and marks obtained:

  ----------------------- ------------- --------------- ------------------- --------------
  ***Name of School/      ***Degrees    ***Date of      ***Division/Class   ***Total Marks
  College/University***   Obtained***   Degree          Obtained***         Obtained***
                                        Conferment***                       

                                                                            

                                                                            

                                                                            

                                                                            
  ----------------------- ------------- --------------- ------------------- --------------

7\. What was your major subject in BA Honors and MA?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8\. What were your minor (subsidiary) subjects?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9\. What is your proposed major field of study:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10\. In what specific area of your field do you plan to specialize?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11\. Please write a succinct statement as to why you are interested in
the Hubert H. Humphrey Fellowship program and how you think that your
participation in this program will benefit you and your country? Please
use only the space provided below for this statement.

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12\. Have you taken TOEFL? Yes \_\_\_\_\_\_\_\_\_\_\_\_\_\_ No
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If yes, please provide: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Date of Exam) (Score)

Have you ever taken IELTS? Yes \_\_\_\_\_\_\_\_\_\_\_\_\_ No
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If yes, please provide: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Date of Exam) (Score)

13\. Please describe the nature of the job that you perform:

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14\. List of publications, if any:

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15\. Academic Honors/distinctions:

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16\. Office address:
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17\. Residential address:
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18\. Office Telephone: Residence telephone:

Fax: Mobile:

E-mail: E-mail:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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Date Signature

**NOTE:** Please attach copies of certificates and mark sheets covering
your entire period of study at school, college and university.

Doc:share\\hhhform.fah