STUDY OF THE UNITED STATES INSTITUTES

FOR SCHOLARS

APPLICATION FORM

Please select the institute(s) to which you want to apply. If you wish to apply to more than
one institute, please submit one application form for each institute.

 Youth, Workforce Development, and Closing the Skills Gap

 Journalism and Media
 American Culture and Values
 American Politics and Political Thought
 Contemporary American Literature
 Religious Pluralism in the United States
 U.S. Foreign Policy

Full Name (exactly as it appears in

passport)
Gender
Date of Birth (month/day/year)
Country and City of Birth
Citizenship(s)
Country of Residency

1- Contact Information

Address
City and Postal Code
Country
Telephone Number(s)
E-mail Address
Emergency Contact Name & Relationship
Emergency Contact Phone and Email

2- Medical, Physical, Dietary or other Personal Considerations:

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

_______________________________________________________________________________________
 3- Current Position, Title, Institution

Senior University Official (President, Provost), Government Minister, Senior Executive, etc.
University Dean, Government Advisor, Vice President, Junior Executive
Senior Professor, Department Chair, Director, Editor, Officer, etc.
Associate Professor, Senior Researcher/Think-Tank Fellow, Senior Staff, etc.
Assistant Professor, Assistant Editor, Coordinator, Mid-level Staff Researcher/Think-Tank Fellow, etc.
Lecturer, Teacher, Consultant
Teaching Assistant, Instructor
Other (please specify)

Title: ________________________________________________
Institution Name: ________________________________________________

4- Work Experience, including previous positions and titles

From: mm/yy To: mm/yy Title & Institution Part/Full Time

Position

5- Education, Academic, and Professional Training

Please list all degrees beginning with the most recent.

Degree Earned Year Earned Specialization & Institution

6- Additional Professional Training

7- Active Professional Memberships:

List any active professional memberships. These should not include university committee work or other
professional duties directly related to your current employment.
 Position Title Organization

8- Publications Related to the Institute Theme (up to 10)

Please list all foreign titles in English, including books; chapters; journal and newspaper articles; web
articles; etc.

Publication Type (book, article, etc) Year Title of Publisher

9- Previous Travel to the United States

Purpose Dates and duration of stay Description

10- Family/friends residing in the United States

Please include city and state (ie, John Doe – Chicago, IL).

11- Professional Responsibilities: Please discuss your professional responsibilities, including research
interests, administrative responsibilities (ex. curriculum design), and/or other pertinent information.

12- Current Courses Taught:

Course Title Level of Class hours Nb of U.S. Studies

Students per semester Students Content (%)
 13- Current Student Advising:
Outside of your formal teaching, please describe any assistance you provide to students in helping them
identify and make progress toward their personal and career goals. This section can also include your
supervision of PhD and graduate students.

Number of Students Advised Studying Grade Level of Students (high school, Hours of Advising
U.S.-Related Topics undergraduates, masters, PhD) Per Student Per
Year

14- Personal Essay (limit 250 words): Please convey why you are interested in participating in the institute
to which you are applying, what you expect to gain, and what you will contribute to the institute. Your
statement should also address how you will leverage the experience to make a difference in your home
institution and in Tunisia by updating coursework, creating new courses, launching new research,
publishing new work, building institutional linkages, etc.

How did you learn about this program?

U.S. Embassy website A friend/colleague who previously participated in SUSI

U.S. Embassy Facebook page Newspaper
Email from U.S. Embassy Internet site (please name)
University (announcement on campus) Other (please specify)
Email from a friend/colleague