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**FULBRIGHT PROGRAM**

> **[Application for foreign language teaching assistantship in the
> United States]{.underline}**

***You must have a copy of the [Instructions]{.underline} for this
application with you while attempting to complete application fields.
Please note, there are slight differences between this copy of the
application and the online version due to technology***

**General Information**

**1.** APPLICANT SUBMISSION NAME:

The first, middle and last (family) name provided on this application
should be spelled exactly as it appears in your passport. If you do not
have a passport, you should submit the first, middle and last name
spelling that would likely appear on your passport.

**Do you currently have a passport?** Yes No

**2.** NAME **(as it appears or will appear on your passport**)

###  [Family]{.underline} [First]{.underline} [Middle]{.underline}

Mr. 

Ms. 

**4.** DATE OF BIRTH:
(Month/Day/Year)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **5.**
CURRENT AGE: \_\_\_\_\_\_\_\_\_\_\_\_

**6.** GENDER\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **7.**
BIRTHPLACE: (City, State/Province,
Country)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**8.** COUNTRY OF CITIZENSHIP\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **9.**
COUNTRY OF RESIDENCE \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**10**. You must answer **ALL** of the following questions. DO YOU NOW
OR HAVE YOU EVER HELD:

U.S. CITIZENSHIP? Yes No

U.S. DUAL CITIZENSHIP? Yes No

U.S. PERMANENT RESIDENCY? Yes No

HAVE YOU EVER APPLIED FOR U.S. PERMANENT RESIDENCY (i.e. GREEN CARD)?
Yes No

IF "YES", WHAT STATEMENT IS TRUE OF YOUR APPLICATION?:

My application was denied

My application is still pending

**PLEASE SELECT ONLY ONE OF THE FOLLOWING REGARDING YOUR POSSIBLE ROLE
ON A U.S. UNIVERSITY CAMPUS**

**11.** IN YOUR ROLE AS A LANGUAGE ASSISTANT ON A U.S. UNIVERSITY
CAMPUS, I AM WILLING TO:

>  Perform actual classroom teaching duties
>
>  Be primarily an assistant
>
>  Both teach and assist

**12.** IS THERE A PARTICULAR REGION IN THE U.S. THAT INTERESTS YOU?
**([limiting the regions may reduce the likelihood of final
selection]{.underline}**) Yes No

*You may visit
[http://maps.howstuffworks.com/united-states-regional-map.htm]{.underline}
to view U.S. regions.*

**13.** IF THERE IS A SPECIFIC REGION THAT INTERESTS YOU, PLEASE
INDICATE IT HERE. IF THERE IS NOT A SPECIFIC REGION, PLEASE SELECT N/A.

Northeast Southeast Midwest Southwest West Coast  N/A, I would
accept all

**14**. IS THERE ANY COLLEGE OR UNIVERSITY PROFILE OF WHICH YOU
DISAPPROVE? Please select all that apply **(an inability to adapt to a
new or different environment may reduce the likelihood of final
selection).**

 Single gender student body

 Urban location

 Rural location

 Small population

 Large population

 Little ethnic diversity

 Great ethnic diversity

 Offers coursework on an audit basis

 Requires specific coursework on a credit basis

 N/A, I would accept all

**15.** OBJECTIVES: Write a clear and detailed description of your
objectives.

Please see the \"Tips\" in the *Instructions* before submitting your
essay.

**16. NON-ACADEMIC INTERESTS**: Please list any non-academic interests
(e.g. sports, music, art, etc) Include information about your experience
in these areas.

*Note: Please limit your response to the size of this text box. Anything
over this size will not display or print on your submitted application.*

**17. ARE YOU PURSUING ANY OTHER SCHOLARSHIP, FELLOWSHIP OR EMPLOYMENT
THAT WOULD SUPERCEDE YOUR PARTICIPATION IN THE FLTA PROGRAM SHOULD IT BE
OFFERED? PLEASE EXPLAIN:**

*Note: Please limit your response to the size of this text box. Anything
over this size will not display or print on your submitted application*

### 18. DEGREE: PLEASE INDICATE THE LAST DEGREE [YOU COMPLETED]{.underline}. PLEASE DO NOT LIST CERTIFICATES IN THIS SECTION.

  ----------------------------------- -----------------------------------
  **Degree (ex. Masters, Bachelors)   **In What Field (please list the
  or Equivalent** **(ex. Magister,    field of study as it appears on the
  Maestria, Bakkalaureus, Maîtrise    degree)**
  )**                                 

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

### 

### 19. EDUCATION: LIST EDUCATIONAL INSTITUTIONS ATTENDED IN REVERSE CHRONOLOGICAL ORDER, INCLUDING ANY IN WHICH YOU MAY BE PRESENTLY ENROLLED. 

+-----------------+-----------+---------+-----------+---------------+
| **Name of       | **Major   | **Dates | **Actual  | ###           |
| Institu         | Field of  | (Month  | Name**    | Date Received |
| tion/Location** | Study**   | and     |           |               |
|                 |           | year)** | **of      | **or          |
|                 |           |         | Degree    | Expected**    |
|                 |           | **From  | or**      |               |
|                 |           | To**    |           |               |
|                 |           |         | **Diploma |               |
|                 |           |         | (Do not   |               |
|                 |           |         | tra       |               |
|                 |           |         | nslate)** |               |
+-----------------+-----------+---------+-----------+---------------+

University or Professional

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

                                                           

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

Secondary

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

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

#####  

###### 

##### 

###### 

**22.** **OCCUPATIONAL EXPERIENCE:** CLEARLY INDICATE YOUR EMPLOYMENT
HISTORY, BEGINNING WITH YOUR MOST RECENT POSITION. YOU MUST COMPLETE ALL
RELEVANT FIELDS.

+------------------------+-----------------+---+---+-----------------+
| **Name and address of  | **Type of       | * |   | **Reason for    |
| employer**             | Work**          | * |   | leaving**       |
|                        |                 | D |   |                 |
|                        | **(Position     | a |   | *Note: If       |
|                        | Held)**         | t |   | position still  |
|                        |                 | e |   | held, please    |
|                        |                 | s |   | note as         |
|                        |                 | * |   | "ongoing"*      |
|                        |                 | * |   |                 |
+------------------------+-----------------+---+---+-----------------+
|                        |                 | * | * |                 |
|                        |                 | * | * |                 |
|                        |                 | F | T |                 |
|                        |                 | r | o |                 |
|                        |                 | o | * |                 |
|                        |                 | m | * |                 |
|                        |                 | * |   |                 |
|                        |                 | * |   |                 |
+------------------------+-----------------+---+---+-----------------+

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

                                                       

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

**23**. **TEACHING EXPERIENCE:** IF YOU CURRENTLY OR PREVIOUSLY HELD A
LANGUAGE TEACHING POSITION, PLEASE ESTIMATE THE NUMBER OF MONTHS OR
YEARS YOU OCCUPIED THE POST?

**\_\_\_\_\_\_** Years \_\_\_\_\_\_ Months

24\. LIST PROFESSIONAL SOCIETIES, FRATERNITIES OR OTHER ORGANIZATIONS IN
WHICH YOU NOW HOLD MEMBERSHIP OR IN WHICH YOU HAVE BEEN ACTIVE IN THE
PAST (Indicate if you have held elective office) *Note: Please limit
your response to the size of this text box. Anything over this size will
not display or print on your submitted application.*

25\. IF YOU HAVE TRAVELED OR LIVED IN ANY COUNTRY OTHER THAN YOUR OWN
INDICATE PLACES, DATES AND REASONS. *Note: Please limit your response to
the size of this text box. Anything over this size will not display or
print on your submitted application.*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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####### 28. Provide the name, address and telephone number of individuals to be notified in case of emergency

  ----------------------- ----------------------- -----------------------
  In Home Country         In the United States    List Below any close
                                                  relatives or friends in
                                                  the United States
                                                  (name, address, and
                                                  relationship)

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

**29.** **COURSE INTEREST:** The FLTA Program is a non-degree program.
You will be expected to take/attend one course in American Studies and
three additional courses at your host institution on a credit or audit
basis for enrichment purposes. Name three courses you may be interested
in taking/attending and why?

  ------------------- ---------------------------------------------------
  Course              Reason

  1\.                 

  2\.                 

  3\.                 
  ------------------- ---------------------------------------------------

**30. TEACHING THE LANGUAGE OF NOMINATION:** You may be asked to teach
your own class. If so, what teaching methodologies and techniques would
you apply to the teaching of the language for which you have been
nominated? Mention any innovative approaches you have utilized as a
teacher or encountered as a learner that you may employ.

**31. SHARING YOUR CULTURE:** Imagine you have to represent your country
at an International Festival your host school is organizing. What
aspects of your language and culture would you choose to present?

**32.** [**Personal Statement**:]{.underline}

Please write a narrative concerning your personal history and long-term
goals; it should not be a mere listing of facts, nor should it be a copy
of the essay provided in *Objectives* of this application. Please see
the *Instructions* before submitting your essay.

***COMPLETING YOUR APPLICATION***

**33. In order to complete your application, you must go to the
navigation bar on the left and click on *[Supplemental
Forms]{.underline}*. You must complete the following documents under
*[Supplemental Form]{.underline}*:**

**1) Personal Information form: Please print, complete and submitted to
your home country contact .**

**2) Reference forms: These are recommendation letters. [You must submit
three]{.underline}. You can utilize a hard copy print out, which you
will submit to your home country contact or click
*[Recommendations]{.underline}* on the navigation bar to register a
recommender. The recommender will have to go online to complete his/her
reference form.**

**3) Medical form: Please print a copy. If you are notified that you are
a nominee for the program, you must complete and submit this form to
your home country contact or to the FLTA Program address above.
Completion of the medical form constitutes a full application, but does
not guarantee placement.**