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The American Center

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

**Momenshahi House**

**House No. 110, Road No. 27**

**Banani, Dhaka-1213**

**Tel: 8837150-54, Fax: 9881677 & 9885688, E-mail: dhakaPA@state.gov**

**[Pre-Application for the Fulbright Junior Scholarship
Program]{.underline}**

**[FY 2007-2008]{.underline}**

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

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

4\. Country of Residence \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 5. Country of
Citizenship \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. Current official designation and name of office
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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7\. Past
Positions\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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8\. 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***                       

                                                                            

                                                                            

                                                                            

                                                                            

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

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

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

11\. What is your proposed major field of study?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

13\. Please write a succinct (not more than 300 words) statement as to
why you are interested in the Fulbright Scholarship program and how you
think that your participation in this program will benefit you and your
country?

14\. Have you taken TOEFL or GRE / GMAT / When? Yes
\_\_\_\_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_\_\_

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

(TOEFL) (GRE) (GMAT)

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

16\. List of publications, if any:

17\. Academic Honors/distinctions:

18\. Do you possess a residency status from any other country than
Bangladesh?

19\. Do you have an immigration application pending for any other
country?

20\. Have you applied for any other fellowship?

21\. Office address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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22\. Residential address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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23\. Telephone/Fax/E-mail: Office:

Residence:

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

Date Signature