Application Form FFSP

8/3/2019 Application Form FFSP

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FULBRIGHT PROGRAMAPPLICATION FOR STUDY IN THE UNITED STATES

FOR A FELLOWSHIP, SCHOLARSHIP, ASSISTANTSHIP

OR OTHER EDUCATIONAL GRANT(Please read instructions carefully. All sections should

be completed in English and be typewritten.)

1. NAME OF APPLICANT

Mr.Ms.

Family First Middle Initial

.

3. PERMANENT ADDRESS: 4. HOME PHONE:

5. DATE OF BIRTH: (Month-Day-Year)

6. GENDER:

Male Female

7. OFFICE PHONE:

8. EMAIL:

9. BIRTHPLACE: (City, State/Province, Country)

10. COUNTRY OF RESIDENCE:

11. MARITAL STATUS: (Single, Married, Divorced, Separated, Widow,Widower, etc.)

12. AGES OF CHILDREN, IF ANY:

13. CITIZENSHIP: 13.a DO YOU NOW HAVE, OR HAVE YOU EVER HELD:

U.S. CITIZENSHIP? Yes NoDUAL CITIZENSHIP? Yes NoU.S. PERMANENT RESIDENCY? Yes No

13.b HAVE YOU EVER APPLIED FOR A U.S. VISA? Yes NoIF YES, WHEN? WAS THE VISA GRANTED? Yes No IF YES, WHAT TYPE OF VISA?DO YOU HAVE IMMEDIATE RELATIVES IN THE U.S.? Yes No IF YES, EXPLAIN RELATIONSHIP:

STUDY PLANS

14. WHAT IS YOUR PROPOSED MAJOR FIELD OF STUDY AND IN WHAT SPECIFIC AREA OF YOUR FIELD DO YOU PLAN TO SPECIALIZE? PLEASE

REFER TO THE LIST OF MAJORS ENCLOSED.

MAJOR: SPECIFIC AREA:

15. DEGREE OBJECTIVE: Doctorate Masters Non-Degree Visiting Researcher

2. NAME ON PREVIOUS ACADEMIC RECORDS: (If different from above)

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EXAMINATION RESULTS16. EXAMINATION DATES AND TEST SCORES: (Date if taken or future date for taking exams (Month/Year))

Date Score Percentile Date Verbal

Score

% Quantitative

Score

% Analytical

Score

%

TOEFL GRE

GeneralExam

TSE

TWE Date Score % Subject Name

GMAT GRE

SubjectExam IELTS

EDUCATION

17.LIST EDUCATIONAL INSTITUTIONS ATTENDED IN REVERSE CHRONOLOGICAL ORDER, INCLUDING ANY IN WHICH YOU MAY BE PRESENTLY

ENROLLED:

INSTITUTION AND LOCATION

(List in reverse order)

MAJOR FIELD OF

STUDY

DATES

(Month and Year)

From To

ACTUAL NAME OF

DEGREE OR DIPLOMA

(Do not translate)

DATE RECEIVED O

EXPECTED

18. LIST SCHOLARSHIPS OR FELLOWSHIPS HELD AT PRESENT OR IN THE PAST: (Give source or sponsor, amount, where held, and duration.)

19. INDICATE ANY ACADEMIC HONORS OR PRIZES WHICH YOU HAVE RECEIVED, WITH TITLES AND DATES;

20. LIST ANY BOOKS, ARTICLES OR THESES PUBLISHED BY YOU, ESPECIALLY IN YOUR PROPOSED FIELD OF STUDY: (Give title, place and date

of publication)


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21. LIST PROFESSIONAL SOCIETIES, FRATERNITIES OR OTHER ORGANIZATIONS IN WHICH YOU NOW HOLD MEMBERSHIP OR IN WHICH YOU

HAVE BEEN ACTIVE IN THE PAST: (Indicate if you have held an elective office.)

22. TEACHING EXPERIENCE: (Including any teaching positions you have held or currently hold.)

23. RESEARCH: (Including any research you have completed or in which you are currently involved.)

Application Pag

Application P


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NAME OF APPLICANT: COUNTRY:

24.

STUDY OBJECTIVESWrite a clear and detailed description of your study objectives. Be specific about your major field and your specialized interests within this field.Describe the kind of program you expect to undertake, and explain how your study plan fits in with your previous training and your future objectives.Your statement is an essential part of your application. Unclear, incomplete or impractical proposals can result in your being referred to a university

not suited to your scholastic needs, or your not being accepted by any university. Do not mention specific U.S. universities at which you would

like to study. Do not exceed the space available. If you need additional space, please prepare a separate sheet and insert it after printing the

application.


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Application Page


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25.

PERSONAL STATEMENT

Please provide a narrative statement discussing your professional, academic and future plans. It should not be a mere listing of facts. It should includeinformation about your education, practical experience, special interests, career plans, and your purpose in applying for study in the U.S. Describe any

significant factors that have influenced your educational or professional development. Comment on the number of years of practical experience alreadycompleted in the field in which academic work will be done in the U.S. and describe briefly the most advanced courses already pursued in their field of

study. Do not mention specific U.S. universities at which you would like to study in your Personal Statement. Do not exceed the space available

If you need additional space, please prepare a separate sheet and insert it after printing the application.

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26. KNOWLEDGE OF LANGUAGES: (Rate yourself Excellent, Good or Fair. Include all languages in which you have some competence.)

Mother Tongue

LANGUAGE READING WRITING SPEAKING

English

26.a HOW MANY YEARS HAVE YOU STUDIED ENGLISH?

27. OCCUPATIONAL EXPERIENCE: (List positions held, beginning with the most recent employment, if any.)

NAME AND ADDRESS OF EMPLOYER TITLE/TYPE OF WORK DATES (Month and year)From To

28. IF YOU HAVE TRAVELLED, LIVED, OR STUDIED IN ANY COUNTRY OTHER THAN YOUR OWN FOR MORE THAN A MONTH, INDICAT

PLACES, DATES AND REASONS:

29. PLEASE PROVIDE THE NAME, ADDRESS AND TELEPHONE NUMBER OF INDIVIDUALS TO BENOTIFIED IN CASE OF AN EMERGENCY:

30. PLEASE LIST ANY CLOSE RELATIVES ORFRIENDS IN THE UNITED STATES: (Name,

address and relationship)IN YOUR HOME COUNTRY IN THE UNITED STATES

31. PLEASE DESCRIBE ANY PHYSICAL IMPAIRMENT YOU MAY HAVE: (This information is gathered for statistical purposes and to ensure appropria

placement. IIE does not discriminate on the basis of race, color, religion, sex, national origin, and/or physical impairment.)

32. FUTURE PLANS: (Describe the career you plan to pursue after completion of study or research in the U.S. (e.g., teaching, government, business,

industry or any plans you might have for continued study or research in your home country). Also indicate if you will be returning to former employment,

or if you have been promised a position in your home country after completing your U.S. training).

BY MY SIGNATURE, I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION PROVIDED IN MY APPLICATION IS ACCURATE ANDCOMPLETE.

SIGNATURE OF APPLICANT: DATE:

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FULBRIGHT PROGRAMAPPLICATION FOR STUDY IN THE UNITED STATES

FOR A FELLOWSHIP, SCHOLARSHIP, ASSISTANTSHIP OR OTHER EDUCATIONAL GRANT

CONFIDENTIAL LETTER OF REFERENCE

This letter of reference must be written by a teacher under whom the applicant has studied or pursued research in the proposed field of study or by someonwho has supervised the applicant in work related to the proposed field of study. This letter must be typewritten and in English. If not in English, then aaccurate translation must be attached.


NAME OF REFEREE:

TITLE

INSTITUTION OR BUSINESS

1. HOW LONG HAVE YOU KNOWN THE APPLICANT?

2. IN WHAT CAPACITY HAVE YOU KNOWN THE APPLICANT? (mark one of the boxes below)

Teacher or

Professor

Employer or Job Supervisor Research Adviser Other (Please specify)

3. PLEASE PROVIDE A CANDID EVALUATION OF THE APPLICANTS PAST PERFORMANCE AND ABILITY TO PURSUE AND SUCCESSFULLY

COMPLETE A PROGRAM OF STUDY IN THE PROPOSED FIELD. Your statement will be given considerable importance by the universities reviewingthis students application and should, therefore, be as complete and detailed as possible. Your comments should be continued on the following page ifmore space is required.

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4. IN THIS RATING CHART, PLEASE EVALUATE THE APPLICANT IN COMPARISON WITH OTHER STUDENTS WHOM YOU HAVE KNOWN

DURING YOUR POFESSIONAL CAREER.

Excellent Very Good Average Below Average

Intellectual Ability

Knowledge of Field

Work Habits

Motivation to Pursue Graduate Study

Seriousness of Purpose

Potential For Significant Future Contribution in Field

Resourcefulness and Initiative

Emotional Maturity

Adaptability to New Situations

Leadership Qualities

Teaching Potential

NAME (print):

SIGNATURE: DATE:

PLEASE PLACE IN A SEALED ENVELOPE TO BE RETURNED DIRECTLY TO: SELECTION COMMITTEE, FULBRIGHT

COMMISSION IN ECUADOR, ALMAGRO N25-41 Y COLON, QUITO, ECUADOR. UNDER NO CIRCUMSTANCES SHOULD THE

COMPLETED FORM BE RETURNED TO THE APPLICANT IN AN UNSEALED ENVELOPE.

NOTE: The Fulbright Commission in Ecuador cannot guarantee this letters confidentiality once it becomes part of its records.


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AGRICULTURE

. AGRICULTURAL ECONOMICSa. Agribusinessb. Agricultural Financec. Agricultural Marketingd. Agricultural Policye. Farm Management. Land Economics

g. Natural Resource Economicsh. Production Economic

2. AGRICULTURAL ENGINEERINGa. Agricultural Waste Managementb. Food Engineeringc. Food Engineering/Process Controld. Forest Engineeringe. Handling/Processing/Storage of Agricultural

Products. Irrigation & Drainage Systems/Engineering

g. Post-harvest Technologyh. Power & Machinery. Soil & Water Engineering

Wind Erosion

3. AGRICULTUREa. Agronomyb. Animal Nutri tionc. Dairy Scienced. Fruit/Vegetable Productione. Horticulture. Ornamental Horticulture

g. Pest Control/Entomologyh. Plant Breeding/GeneticsPlant PathologyPlant Science

k. Tropical Agriculture

4. NATURAL RESOURCESa. Forestryb. Natural Resource Managementc. Range Managementd. Fish, Game and Wildlife Managemente. Environmental Science

5. VETERNARY MEDICINEa. Theriogenologyb. Toxicologyc. Surgeryd. Neurologye. Small-animal Medicine. Large-animal Medicine

THE ARTS

6. DANCEa. Balletb. Dance Educationc. Modern Dance

7. FINE AND APPLIED ARTSa. Art Educationb. Computer Artc. Craftsd. Filmmakinge. Graphic Design. Illustration

g. Painting and Drawingh. Photography

PrintmakingSculpture

8. MUSICa. Music Educationb. Music History and Literaturec. Musicologyd. Performancee. Theory and Composit ion

9. THEATER ARTSa. Actingb. Costumec. Designd. Directinge. Dramaturgy & Dramatic Criticism. Playwriting

g. Stage Designh. Stage Management. Technical Design & Production

ENGINEERING

10. AEROSPACE & MECHNICAL ENGINEERINGa. Acousticsb. Aerodynamicsc. Aeroelasticityd. Aeronautical & Astronautical Systemse. Air Conditioning and Ventilationf. Applied Mechanicsg. Computer-aided Designh. Design and Systems Analysisi. Energy Systems

j. Fl ight Dynamics and Controlk. Fluid Mechanicsl. Gasdynamicsm. Guidance and Controln. Heat Transfer o. Instrumentationp. Manufacturing Processes and Designq. Propulsionr. Solid Mechanicss. Structural Dynamicst . Structural Mechanicsu. Thermal Science

11. CHEMICAL ENGINEERINGa. Bio-chemical Engineeringb. Catalysis & Kineticsc. Coal Conversiond. Colloid /Interfacial Sciencese. Heat /Mass Transferf . Pollut ion Control

g. Polymer Processingh. Process Synthesis and Designi. Reactor Engineeringj. Rheologyk. Separation Processesl. Transport Phenomena

12. CIVIL AND ENVIRONMENTAL ENGINEERINGa. Construction Engineering/Managementb. Environmental/Sanitary Engineeringc. Geodesy/Survey Engineeringd. Geotechnical Engineering/Soil or Rock

Mechanics/Earthquakee. Structural Engineeringf. Transportation Engineeringg. Water Resources Engineering/Hydaulics/

Hydrology

13. ELECTRICAL ENGINEERINGa. Biomedical Engineering

b. Computer Engineering (hardware)c. Control Engineeringd. Network/Systems Engineeringe. Power Engineeringf. Roboticsg. Telecommunicationsh. Electromagnetics

14. GEOLOGICAL, PETROLEUM & MININGENGINEERINGa. Dri ll ing Engineeringb. Enhancing Oil & Gas Recoveryc. Exploration & Developmentd. Mine Planning/Designe. Mine Ventilationf . Petroleum Ref iningg. Reservoir Engineeringh. Rock Mechanicsi. Well Logging

15. INDUSTRIAL & SYSTEMS ENGINEERING &OPERATIONS RESEARCH

a. Applied Probability and Statisticsb. Artificial Intelligencec. Computer Integrated Managementd. Energy Managemente. Engineering Economicsf. Engineering Managementg. General Operations Researchh. Health Systems Engineeringi. Human Factors Engineering (Ergonomics)j. Industr ial Roboticsk. Manufacturing/Production Systemsl. Production Managementm. Quality Control/Reliability Simulation Systemsn. Safety Engineeringo. Stochastic Processesp. Systems Analysis and Designq. Technology Management

16. MATERIALS SCIENCE & METALLURGICALENGINEERINGa. Alloy and Crystal Scienceb. Ceramic Engineeringc. Chemical Metallurgyd. Corrosion Sciencee. Electronic Materialsf . Extractive Metallurgyg. Mechanical Metallurgyh. Physical Metallurgyi. Polymer Materialsj. Welding Engineering

17. NUCLEAR ENGINEERINGa. Applied Radiation Physicsb. Applied Solid State Physicsc. Fissiond. Fusione. Nuclear Fuels and Materialsf. Nuclear Physicsg. Nuclear Power Plant Designh. Plasma Physicsi. Quantum Electronics j. Radiation Measurementk. Reactor Engineering

18. OCEAN ENGINEERINGa. Coastal & Offshore Engineeringb. Marine Hydrodynamicsc. Naval Architectured. Ocean Engineering Power Systemse. Ocean Engineering Transportation Systemsf. Underwater Acoustics

PHYSICAL SCIENCES

19. ASTRONOMY & PHYSICSa. Acousticsb. Astronomyc. Astrophysicsd. Atomic/Molecular Physicse. Biophysicsf. Chemical Physicsg. Condensed Matterh. Fusion and Plasmasi. High Energy, Elementary Particles and Fieldj. Laser Physicsk. Low Temperature Physicsl. Medical & Health Physicsm. Nuclear Physicsn. Opticso. Physics Educationp. Polymer Physicsq. Solid State Physicsr. Spectroscopys. Statistical & Thermal Physicst . Theoret ical Physics

20. BIOLOGICAL SCIENCESa. Bacteriologyb. Biochemistryc. Botanyd. Ecologye. Entomologyf. Epidemiologyg. Geneticsh. Immunologyi. Marine Biologyj. Microbiologyk. Molecular and Cell Biology

l. Neurobiologym. Parasi tologyn. Virologyo. Zoology

21. CHEMISTRYa. Analytical Chemistryb. Chemical Physicsc. Crystal lographyd. Environmental Chemistrye. Inorganic Chemistryf. Nuclear Chemistryg. Organic Chemistryh. Pharmaceutical Chemistryi. Physical Chemistry j. Polymer Chemistryk. Theoretical Chemistry

22. COMPUTER SCIENCEa. Artificial Intelligence

b. Automation Technology

Confidential Letter Reference Page

LIST OF MAJORS


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c. Computer Designd. Computer Graphicse. Database Theory & Management. Image Processing

g. Management Information Systemsh. Microprocessors

Numerical Analysis. Programming Languagesk. Robotics

Sof tware Engineeringm. Switching Theoryn. Information Science

23. GEOSCIENCESa. Atmospheric Sciences and Meteorologyb. Geology

c. Geophysicsd. Hydrologye. Mineralogy. Oceanography

g. Paleontologyh. Petrology

Seismology

24. MATHEMATICSa. Mathematicsb. Applied Mathematicsc. Pure Mathemat icsd. Probability/Statisticse. Computer Science. Computer Programming

g. Data Processingh. Information Sciences & Systems

Systems Analysis

PROFESSIONAL & EDUCATIONAL STUDIES25. ARCHITECTUREa. Architectural Historyb. Historic Preservationc. Environmental Designd. Industr ial Designe. Interior Design. Landscape Architecture

g. Urban Designh. General Architecture: Design, Theory,

Methods

26. ARTS ADMINISTRATIONa. Conservation/Restorationb. Museum Studiesc. Visual Studies

27. ART THERAPYa. Art Therapy

b. Dance/Movement Therapyc. Drama Therapyd. Music Therapy

28. BUSINESSADMINISTRATION/MANAGEMENT

a. Accountingb. Business Economicsc. Entrepreneurial Studiesd. Financee. Human Resource Management. Industrial Administration

g. Insuranceh. International Business. Management Information Systems

Marketingk. Organizational Behavior. Production/Operations Management

m. Not-for-profit/Non-profit Management

n. Quantitat ive Analysiso. Real Estatep. Taxationq. Telecommunications Management

29. EDUCATIONa. Elementary, Secondary, and Higher Educationb. Adult/Continuing Educationc. Art/Music/Dance Educationd. Bil ingual Educatione. Business Educat ion. Curriculum & Instruction

g. Early Childhood Educationh. Educational Administration. Educational Measurements/Statistics

Educational Philosophyk. Educational Planning, Policy and Leadership. Educational Psychology

m. Foundations of Educationn. Guidance and Counseling

o. Instructional Media/Educational Technology

p. International Educationq. Language Arts Educationr. Mathematics Educations. Physical Education and Recreationt. Remedial Readingu. Science Educationv. Special Educationw. Teaching English as a Second Languagex. Vocational Education

30. HEALTH SCIENCES AND NURSINGa. Allied Health Professionalsb. Food Science/Nutrit ionc. Occupational Therapyd. Pharmacologye. Pharmacy

f. Physical Therapyg. Public Healthh. Speech Pathology/Audiology

31. JOURNALISM AND MASSCOMMUNICATIONS

a. Advertisingb. Broadcast Journalismc. Communication Theory and Researchd. Development Communicationse. Health Communicationf. International Communicationsg. Media Managementh. Photojournalismi. Political Communicationj. Print Media/Journalismk. Public Relationsl. Science Journal ismm. Speech Communication

32. LAWa. Administrative Lawb. Comparative/International Lawc. Consti tutional Lawd. Corporation/Commercial Lawe. Criminal Lawf. Environmental Lawg. Human Rightsh. Labor Lawi. Law of the Sea/Marit ime Lawj. Natural Resource Lawk. Taxation

33. LlBRARY SCIENCEa. Academic Librarianshipb. Archives & Manuscript Administrationc. Information Scienced. Law Librarianshipe. Library Management & Administrationf. Medical/Health Science Librarianship

g. Music Librarianshiph. Organization of Library Collectionsi. Public Librarianshipj. Rare Books and Special Collectionsk. Reference and Bibliographic Materiall. School Librarianship

34. PUBLIC ADMINISTRATIONa. Comparative Administration & Developmentb. Economic Developmentc. Environmental and Resource Managementd. Health Policy & Social Welfaree. Health Services Administrationf. International Affairs and Development

Managementg. Local Government Administrationh. Population Researchi. Public Affairs Managementj. Public Finance Administrationk. Public Management Information Systems

l. Public Personnel/Human ServicesAdministration

m. Public Policy Analysisn. Public Sector Labor Relationso. Science Policyp. Technology & Information Policyq. Telecommunications Managementr. Urban Affairs/Urban Management

35. SOCIAL WORKa. Family & Childrens Servicesb. Health Care Systemsc. Industrial Social Welfared. Social Policy, Administration & Community

Developmente. Social Services for the Aging/Gerontologyf. Social Theoryg. Social Welfare Administrationh. Social Work Research

36. TEACHING ENGLISH AS A SECONDLANGUAGE

a. Applied Linguisticsb. Bilingual/Bicultural Educationc. Foreign Language Education

37. URBAN & REGIONAL PLANNINGa. Community Services Planningb. Developing Countriesc. Economic Developmentd. Environmental Planninge. Housingf. Land Use & Developmental Planningg. Planning Designh. Planning Methods & Theoriesi. Public Policy Analysis

j. Transportation Planningk. Urban/Regional Planning

SOCIAL SCIENCES & THE HUMANITIES

38. AMERICAN STUDIES

39. Anthropologya. Anthropological Linguisticsb. Archaeologyc. Cultural/Social Anthropologyd. Ethnologye. Historical/Prehistorical Anthropologyf . Medical Anthropologyg. Physical Anthropologyh. Urban Anthropology

40. AREA STUDIESa. African Studiesb. Asian Studies

c. Eastern European Studiesd. Judaic Studiese. Latin American Studiesf. Middle Eastern Studiesg. Womens Studies

41. ART HISTORY & ARTS ADMINISTRATIONa. Conservation/Restorationb. Museum Studiesc. Visual Arts

42. CREATIVE WRITING & LITERATUREa. American Literatureb. Classicsc. Comparative Literatured. Feminist Literaturee. English Literaturef. Foreign Language Literatureg. Pedagogy

43. ECONOMICSa. Community Developmentb. Consumer Economicsc. Demographic Economicsd. Econometric, Statistical & Mathematical

Methodse. Economic Development Studiesf . Economic Educat iong. Economic Fluctuations and Forecastingh. Economic Growth, Development and Plannin

Theory and Policyi. Economic Historyj. Economic Systemsk. Economics of Technological Changel. Energy Economicsm. Environmental Economicsn. General Economic Theoryo. History of Economic Thought, Methodologyp. International Financeq. International Investments & Aid

r. International Trade Policys. Labor Markets, Public Policyt. Law and Economicsu. Marcoeconomicsv. Manpower Training and Allocationw. Mathematical Economicsx. Medical Economicsy. Microeconomicsz. Polit ical Economicsaa. Regional Economicsbb. Resource Economics, Land Economicscc. Social Economicsdd. Trade Unions, Collective Bargaining, Labor-

Management Relationsee. Urban Economics

44. HISTORY

45. INTERNATIONAL RELATIONS & POLITICASCIENCE

a. Comparative Polit ics


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b. Governmentc. Developmental Studiesd. International Law & Organizationse. International Relations. Political Philosophy

g. Political Theory

46. LINGUISTICS & TRANSLATION STUDIESa. Anthropological Linguisticsb. Applied Linguisticsc. Computational/Mathematical Linguisticsd. Historical/Comparative Linguisticse. Linguistics Study of Specific Languages. Morphology

g. Phonetics/Phonologyh. Semantics

. Theoretical Linguistics. Technical Translationk. Interpretation. Literary Translation & Translation Theory

47. LITERATURE & CREATIVE WRITINGa. American Literatureb. Classicsc. Comparative Literatured. Feminist Literaturee. English Literature

f . Foreign Li teratureg. Pedagogy

48. PHILOSOPHY, RELIGION, AND THEOLOGYa. Aestheticsb. Ethicsc. History of Philosophyd. Logice. Metaphysics/Epistemologyf. Philosophy of Languagesg. Philosophy of Religionh. Philosophy of Sciencei. Philosophy of Social Sciencej. Social/Political Philosophy

49. PSYCHOLOGY

a. Adolescence & Youth Psychologyb. Applied Psychologyc. Behavioral Psychologyd. Child Psychologye. Clinical Psychologyf . Community Psychologyg. Comparative Psychologyh. Counseling Psychologyi. Developmental Psychologyj. Educational Psychologyk. Environmental Psychology

l. Experimental Psychologym. General Psychologyn. Health Psychologyo. Industrial Psychologyp. Neuropsychologyq. Organizational Psychologyr. Personality Psychologys. Physiological Psychologyt. Psyometricsu. School Psychologyv. Social Psychology

50. SOCIOLOGYa. Comparative Sociologyb. Environmental Sociologyc. History of Sociology

d. Industrial Sociologye. Medical Sociologyf . Polit ical Sociologyg. Rural Sociologyh. Sociology of Aging/Social Gerontologyi. Sociology of Sex Rolesj. Sociology of Workk. Urban Sociology

51. OTHER

Documents

Application Form FFSP