Fulbright Belgium: Commission for Educational Exchange between the United States, Belgium, and Luxembourg

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

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

A. Title of Institute

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

Prefix:

Last name

First name

Middle name

C. Gender

Female Male

D. Date of Birth

Example:
mm, dd, yy: 07/31/1980

E. Birth City

F. Birth Country

G. Citizenship

Primary:

Secondary: (if applicable)

H. Residency

Country:

I. 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.

J. Contact Information

Address (No P.O. Box):

City:

Home State or Province:

Postal Code:

Home Country Name:

Email address:

Phone (numbers only, for example 123456789):

K. Current Position, Title, Institution

Primary Position:

Public Secondary School Teacher Private Secondary School Teacher National Curriculum/Exam Developer Teacher Trainer Textbook Writer Other

Title:

Institution Name:

Institution Phone Number:

Institution Address:

Institution Country:

L. Work Experience, including previous positions and titles

From:

To:

Title/Institution (Specify if position is part-time):

M. 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.

Degree earned:

Year Earned:

Specialization/Institution:

Additional Professional Training

N. 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.

Postion:

Title:

Organization:

O. 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,

Publication Type

Year

Title Publisher:

P. Previous Experience in the United States

Purpose:

From:

To:

Description

Q. Family/Friends Residing in the United States

Please include city and state (Example: John Doe - Chicago, IL):

R. Professional Responsabilities

Please discuss your professional responsabilities in greater detail, including research interests, administrative responsabilities (ex. curriculum design), and/or other pertinent information:

S. Current Courses Taught

Course Title:

Level of Students:

Classroom Hours Per Semester:

# Students:

U.S. Studies Content (%):

Other Potential Outcomes:

Please select any likely potential professional outcomes of this program:

Update Existing Course School Curriculum Design New Publication New Professional Organization Create New Course National Curriculum Redesign Professional Promotion New Institutional Linkages Create New Degree Program New Research Project Government or Ministry Policy Raise Institutional Profile

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

Please discuss why you wish to participate in this program. Include how your participation in the institute will enhance your work, improve education about the United States in your community, and help you achieve the "Other Potential Outcomes" you have checked above:

U. References

List names, phone numbers, and e-mail addresses of three people from whom you are requesting letters of reference. The list should include at least one reference from your teaching supervisor, school principal, headmaster or headmistress. The reference form can be found on the www.fulbright.be website and should have been sent to you with your letter of eligibility. Please instruct your recommenders to complete the forms and e-mail them to adviser@fulbright.be from their professional e-mail account before the October 31 deadline.

V. Agreement

I agree that if an award is granted to me I will complete the required program contemplated by the award unless released or disqualified by the agency under whose auspice's the award is granted; that during the tenure of the award I will engage in no occupation or activity other than that assigned to me; that I apply myself diligently to the prescribed program as outlined for me by those under whose supervision I will be placed; that I will return to my country upon completion of my training; and that I will abide by the rules and regulations now or later established in connection with the award. I further agree not to engage either directly or indirectly in any political activity during the tenure of the award.

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.

Name:
Date:

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Commission for Educational Exchange
between the United States, Belgium and Luxembourg
Boulevard de l'Empereur, 4, Keizerslaan
B-1000 Brussels
Telephone inquiries: Monday through Thursday from 2:00 pm to 4:00 pm (02/519/57.72).
adviser@fulbright.be

© Commission for Educational Exchange between the USA, Belgium and Luxembourg