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# 

# VIETNAMESE STUDENT FULBRIGHT FELLOWSHIP PROGRAM

##### Preliminary Data Form

###### Academic Year 2008-09

***INSTRUCTIONS:***

-   This Preliminary Data Form (PDF) must be submitted by **postal mail
    or hand-delivered to the address listed above**. The deadline for
    submission is **Friday, March 2, 2007, at 5:00pm**.

> Emailed or faxed forms will not be accepted.

-   All sections must be completed. Incomplete forms with items left
    blank will **not** be accepted.

-   Attach a photocopy of all **undergraduate and graduate degree
    diplomas**. Copies do not need to be notarized.

-   Attach a photocopy of a **valid TOEFL score**.

-   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 **Friday, March 2, 2007, 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 phone number: (04) 831-4580 x155 or email:
needhamjc@state.gov.

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

**1.** **NAME:      **

Tiếng Việt có dấu: Family (Họ) Middle (Tên đệm) First (Tên)

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

**3. Are you Vietnamese by citizenship? Yes** **No** **(check one)**

(Bạn là người quốc tịch Việt Nam?)

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

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

>      

**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 có dấu)

>      

**Telephone:**      

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   

  University/City   Field/Degree   Date (MM/YY Trường/Tỉnh   Chuyên       Ngày (Từ
                                   to MM/YY)                 ngành/Bằng   Tháng/Năm
                                                                          đến
                                                                          Tháng/Năm)

                                                                               

                                                                               

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

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

  ------------ -------------- ----------- ------------ ------------ -----------
               ENGLISH                                 TIẾNG VIỆT   

  Position     Organization   Date (MM/YY Chức vụ      Tên và địa   Ngày (Từ
               and Location   to MM/YY)                chỉ cơ quan  Tháng/Năm
                                                                    đến
                                                                    Tháng/Năm

                                                                         

                                                                         

                                                                         

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

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

     

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

**For which academic year?**      

*The Fulbright Program 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**: