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
