Study of the U.S. Institutes – Secondary Educator Application

Please note that this program is only available to Belgian citizens.

A. Full Name, exactly as it appears on your passport

B. Gender

C. Date of Birth

D. Birth City

E. Birth Country

F. Citizenship

G. Residency

H. Medical, Physical, Dietary or other Personal Considerations

Please describe any pre-existing medical conditions, including any prescription medication you may be taking, allergies, or other dietary or personal consideration. This will not affect candidate selection, but will enable the host institution to make any necessary accommodations.

I. Contact Information

J. Current Position, Title, Institution

Primary Position:

K. Work Experience, including previous positions and titles

L. Academic and Professional Training

Please list all post-secondary degrees earned, beginning with the most recent. Degrees listed should reflect the closest U.S. equivalent.

Additional Professional Training

M. Active Professional Membership

Active Professional Memberships independent of current professional responsabilities. These should not include university committee work or other professional duties directly related to current employment.

N. Publications Related to the Institute Theme (up to 10)

Please list all foreign titles in English, including whether book, chapter, journal, newspaper article, web article, etc,

O. Previous Experience in the United States

P. Family/Friends Residing in the United States

Q. Evidence of English Fluency

R. Professional Responsibilities

S. Current Courses Taught

Other Potential Outcomes:

T. Personal Essay (limit 4,500 characters):

U. References


     

V. Agreement

   

LAW ON PRIVACY PROTECTION - DISCLOSURE STATEMENT: The information you provide to the Commission for Educational Exchange between the United States of America, Belgium and Luxembourg in this application form will be treated in accordance with the law of December 18, 1992 concerning privacy protection with respect to computer databases. This information is essential to the Commission for Educational Exchange between the United States of America, Belgium and Luxembourg in order to process your application and will be used for this purpose only. However, this information may be communicated to third parties (e.g. potential employers, other foundations, ... ) on their request, if the Commission for Educational Exchange between the United States of America, Belgium and Luxembourg reasonably believes this to be in the interest of the applicant or his/her professional career development. Upon written request addressed to the Commission for Educational Exchange between the United States of America, Belgium and Luxembourg you may have access to your computer record for verification/correction. By typing your name below this application form, you expressly accept the conditions set out above.


I certify that the information given in this application is complete and accurate to the best of my knowledge.