FULBRIGHT PROGRAM APPLICATION 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:

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

6. GENDER:

Male Female 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 No DUAL CITIZENSHIP? Yes No U.S. PERMANENT RESIDENCY? Yes No

13.b HAVE YOU EVER APPLIED FOR A U.S. VISA? Yes No

IF 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 Master�s Non-Degree Visiting Researcher

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

Photo

id22359218 pdfMachine by Broadgun Software - a great PDF writer! - a great PDF creator! - http://www.pdfmachine.com http://www.broadgun.com

EXAMINATION RESULTS 16. 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

TSE

GRE General Exam

TWE

Date

Score

% Subject Name

GMAT

IELTS

GRE Subject Exam

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 OR

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)

Application Page 2

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 Page 3

NAME OF APPLICANT: COUNTRY:

24.

STUDY OBJECTIVES Write 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.

Application Page 4

NAME OF APPLICANT: COUNTRY:

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 include information 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 already completed 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.

Application Page 5

NAME OF APPLICANT: COUNTRY:

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, INDICATE PLACES, DATES AND REASONS:

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

IN YOUR HOME COUNTRY IN THE UNITED STATES

30. PLEASE LIST ANY CLOSE RELATIVES OR FRIENDS IN THE UNITED STATES: (Name, address and relationship)

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

SIGNATURE OF APPLICANT: DATE:

Application Page 6

FULBRIGHT PROGRAM APPLICATION 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 someone who 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 an accurate translation must be attached.

NAME OF APPLICANT: COUNTRY:

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 APPLICANT�S 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 reviewing this student�s application and should, therefore, be as complete and detailed as possible. Your comments should be continued on the following page if more space is required.

Confidential Letter of Reference Page 1

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 letter�s confidentiality once it becomes part of its records. Confidential Letter Reference Page 2

AGRICULTURE

1. AGRICULTURAL ECONOMICS a. Agribusiness b. Agricultural Finance c. Agricultural Marketing d. Agricultural Policy e. Farm Management f. Land Economics g. Natural Resource Economics h. Production Economic 2. AGRICULTURAL ENGINEERING a. Agricultural Waste Management b. Food Engineering c. Food Engineering/Process Control d. Forest Engineering e. Handling/Processing/Storage of Agricultural

Products f. Irrigation & Drainage Systems/Engineering g. Post-harvest Technology h. Power & Machinery i. Soil & Water Engineering j. Wind Erosion 3. AGRICULTURE a. Agronomy b. Animal Nutrition c. Dairy Science d. Fruit/Vegetable Production e. Horticulture f. Ornamental Horticulture g. Pest Control/Entomology h. Plant Breeding/Genetics i. Plant Pathology j. Plant Science k. Tropical Agriculture 4. NATURAL RESOURCES a. Forestry b. Natural Resource Management c. Range Management d. Fish, Game and Wildlife Management e. Environmental Science 5. VETERNARY MEDICINE a. Theriogenology b. Toxicology c. Surgery d. Neurology e. Small-animal Medicine f. Large-animal Medicine

THE ARTS

6. DANCE a. Ballet b. Dance Education c. Modern Dance 7. FINE AND APPLIED ARTS a. Art Education b. Computer Art c. Crafts d. Filmmaking e. Graphic Design f. Illustration g. Painting and Drawing h. Photography i. Printmaking j. Sculpture 8. MUSIC a. Music Education b. Music History and Literature c. Musicology d. Performance e. Theory and Composition 9. THEATER ARTS a. Acting b. Costume c. Design d. Directing e. Dramaturgy & Dramatic Criticism f. Playwriting g. Stage Design h. Stage Management

i. Technical Design & Production

ENGINEERING

10. AEROSPACE & MECHNICAL ENGINEERING a. Acoustics b. Aerodynamics c. Aeroelasticity d. Aeronautical & Astronautical Systems e. Air Conditioning and Ventilation f. Applied Mechanics g. Computer-aided Design h. Design and Systems Analysis i. Energy Systems j. Flight Dynamics and Control k. Fluid Mechanics l. Gasdynamics m. Guidance and Control n. Heat Transfer o. Instrumentation p. Manufacturing Processes and Design q. Propulsion r. Solid Mechanics s. Structural Dynamics t. Structural Mechanics u. Thermal Science 11. CHEMICAL ENGINEERING a. Bio-chemical Engineering b. Catalysis & Kinetics c. Coal Conversion d. Colloid /Interfacial Sciences e. Heat/Mass Transfer f. Pollution Control g. Polymer Processing h. Process Synthesis and Design i. Reactor Engineering j. Rheology k. Separation Processes l. Transport Phenomena 12. CIVIL AND ENVIRONMENTAL ENGINEERING a. Construction Engineering/Management b. Environmental/Sanitary Engineering c. Geodesy/Survey Engineering d. Geotechnical Engineering/Soil or Rock

Mechanics/Earthquake e. Structural Engineering f. Transportation Engineering g. Water Resources Engineering/Hydaulics/

Hydrology 13. ELECTRICAL ENGINEERING a. Biomedical Engineering b. Computer Engineering (hardware) c. Control Engineering d. Network/Systems Engineering e. Power Engineering f. Robotics g. Telecommunications h. Electromagnetics 14. GEOLOGICAL, PETROLEUM & MINING ENGINEERING a. Drilling Engineering b. Enhancing Oil & Gas Recovery c. Exploration & Development d. Mine Planning/Design e. Mine Ventilation f. Petroleum Refining g. Reservoir Engineering h. Rock Mechanics i. Well Logging 15. INDUSTRIAL & SYSTEMS ENGINEERING &

OPERATIONS RESEARCH a. Applied Probability and Statistics b. Artificial Intelligence c. Computer Integrated Management d. Energy Management e. Engineering Economics f. Engineering Management g. General Operations Research h. Health Systems Engineering i. Human Factors Engineering (Ergonomics) j. Industrial Robotics k. Manufacturing/Production Systems l. Production Management m. Quality Control/Reliability Simulation Systems

n. Safety Engineering o. Stochastic Processes p. Systems Analysis and Design q. Technology Management 16. MATERIALS SCIENCE & METALLURGICAL ENGINEERING a. Alloy and Crystal Science b. Ceramic Engineering c. Chemical Metallurgy d. Corrosion Science e. Electronic Materials f. Extractive Metallurgy g. Mechanical Metallurgy h. Physical Metallurgy i. Polymer Materials j. Welding Engineering 17. NUCLEAR ENGINEERING a. Applied Radiation Physics b. Applied Solid State Physics c. Fission d. Fusion e. Nuclear Fuels and Materials f. Nuclear Physics g. Nuclear Power Plant Design h. Plasma Physics i. Quantum Electronics j. Radiation Measurement k. Reactor Engineering 18. OCEAN ENGINEERING a. Coastal & Offshore Engineering b. Marine Hydrodynamics c. Naval Architecture d. Ocean Engineering Power Systems e. Ocean Engineering Transportation Systems f. Underwater Acoustics

PHYSICAL SCIENCES

19. ASTRONOMY & PHYSICS a. Acoustics b. Astronomy c. Astrophysics d. Atomic/Molecular Physics e. Biophysics f. Chemical Physics g. Condensed Matter h. Fusion and Plasmas i. High Energy, Elementary Particles and Fields j. Laser Physics k. Low Temperature Physics l. Medical & Health Physics m. Nuclear Physics n. Optics o. Physics Education p. Polymer Physics q. Solid State Physics r. Spectroscopy s. Statistical & Thermal Physics t. Theoretical Physics 20. BIOLOGICAL SCIENCES a. Bacteriology b. Biochemistry c. Botany d. Ecology e. Entomology f. Epidemiology g. Genetics h. Immunology i. Marine Biology j. Microbiology k. Molecular and Cell Biology l. Neurobiology m. Parasitology n. Virology o. Zoology 21. CHEMISTRY a. Analytical Chemistry b. Chemical Physics c. Crystallography d. Environmental Chemistry e. Inorganic Chemistry f. Nuclear Chemistry g. Organic Chemistry h. Pharmaceutical Chemistry

LIST OF MAJORS

i. Physical Chemistry j. Polymer Chemistry k. Theoretical Chemistry 22. COMPUTER SCIENCE a. Artificial Intelligence b. Automation Technology c. Computer Design d. Computer Graphics e. Database Theory & Management f. Image Processing g. Management Information Systems h. Microprocessors i. Numerical Analysis j. Programming Languages k. Robotics l. Software Engineering m. Switching Theory n. Information Science 23. GEOSCIENCES a. Atmospheric Sciences and Meteorology b. Geology c. Geophysics d. Hydrology e. Mineralogy f. Oceanography g. Paleontology h. Petrology i. Seismology 24. MATHEMATICS a. Mathematics b. Applied Mathematics c. Pure Mathematics d. Probability/Statistics e. Computer Science f. Computer Programming g. Data Processing h. Information Sciences & Systems i. Systems Analysis

PROFESSIONAL & EDUCATIONAL STUDIES

25. ARCHITECTURE a. Architectural History b. Historic Preservation c. Environmental Design d. Industrial Design e. Interior Design f. Landscape Architecture g. Urban Design h. General Architecture: Design, Theory, Methods 26. ARTS ADMINISTRATION a. Conservation/Restoration b. Museum Studies c. Visual Studies 27. ART THERAPY a. Art Therapy b. Dance/Movement Therapy c. Drama Therapy d. Music Therapy 28. BUSINESS

ADMINISTRATION/MANAGEMENT a. Accounting b. Business Economics c. Entrepreneurial Studies d. Finance e. Human Resource Management f. Industrial Administration g. Insurance h. International Business i. Management Information Systems j. Marketing k. Organizational Behavior l. Production/Operations Management m. Not-for-profit/Non-profit Management n. Quantitative Analysis o. Real Estate p. Taxation q. Telecommunications Management 29. EDUCATION a. Elementary, Secondary, and Higher Education b. Adult/Continuing Education

c. Art/Music/Dance Education d. Bilingual Education e. Business Education f. Curriculum & Instruction g. Early Childhood Education h. Educational Administration i. Educational Measurements/Statistics j. Educational Philosophy k. Educational Planning, Policy and Leadership l. Educational Psychology m. Foundations of Education n. Guidance and Counseling o. Instructional Media/Educational Technology p. International Education q. Language Arts Education r. Mathematics Education s. Physical Education and Recreation t. Remedial Reading u. Science Education v. Special Education w. Teaching English as a Second Language x. Vocational Education 30. HEALTH SCIENCES AND NURSING a. Allied Health Professionals b. Food Science/Nutrition c. Occupational Therapy d. Pharmacology e. Pharmacy f. Physical Therapy g. Public Health h. Speech Pathology/Audiology 31. JOURNALISM AND MASS

COMMUNICATIONS a. Advertising b. Broadcast Journalism c. Communication Theory and Research d. Development Communications e. Health Communication f. International Communications g. Media Management h. Photojournalism i. Political Communication j. Print Media/Journalism k. Public Relations l. Science Journalism m. Speech Communication 32. LAW a. Administrative Law b. Comparative/International Law c. Constitutional Law d. Corporation/Commercial Law e. Criminal Law f. Environmental Law g. Human Rights h. Labor Law i. Law of the Sea/Maritime Law j. Natural Resource Law k. Taxation 33. LlBRARY SCIENCE a. Academic Librarianship b. Archives & Manuscript Administration c. Information Science d. Law Librarianship e. Library Management & Administration f. Medical/Health Science Librarianship g. Music Librarianship h. Organization of Library Collections i. Public Librarianship j. Rare Books and Special Collections k. Reference and Bibliographic Material l. School Librarianship 34. PUBLIC ADMINISTRATION a. Comparative Administration & Development b. Economic Development c. Environmental and Resource Management d. Health Policy & Social Welfare e. Health Services Administration f. International Affairs and Development

Management g. Local Government Administration h. Population Research i. Public Affairs Management j. Public Finance Administration k. Public Management Information Systems

l. Public Personnel/Human Services Administration

m. Public Policy Analysis n. Public Sector Labor Relations o. Science Policy p. Technology & Information Policy q. Telecommunications Management r. Urban Affairs/Urban Management 35. SOCIAL WORK a. Family & Children�s Services b. Health Care Systems c. Industrial Social Welfare d. Social Policy, Administration & Community

Development e. Social Services for the Aging/Gerontology f. Social Theory g. Social Welfare Administration h. Social Work Research 36. TEACHING ENGLISH AS A SECOND

LANGUAGE a. Applied Linguistics b. Bilingual/Bicultural Education c. Foreign Language Education 37. URBAN & REGIONAL PLANNING a. Community Services Planning b. Developing Countries c. Economic Development d. Environmental Planning e. Housing f. Land Use & Developmental Planning g. Planning Design h. Planning Methods & Theories i. Public Policy Analysis j. Transportation Planning k. Urban/Regional Planning SOCIAL SCIENCES & THE HUMANITIES

38. AMERICAN STUDIES 39. Anthropology a. Anthropological Linguistics b. Archaeology c. Cultural/Social Anthropology d. Ethnology e. Historical/Prehistorical Anthropology f. Medical Anthropology g. Physical Anthropology h. Urban Anthropology 40. AREA STUDIES a. African Studies b. Asian Studies c. Eastern European Studies d. Judaic Studies e. Latin American Studies f. Middle Eastern Studies g. Women�s Studies 41. ART HISTORY & ARTS ADMINISTRATION a. Conservation/Restoration b. Museum Studies c. Visual Arts 42. CREATIVE WRITING & LITERATURE a. American Literature b. Classics c. Comparative Literature d. Feminist Literature e. English Literature f. Foreign Language Literature g. Pedagogy 43. ECONOMICS a. Community Development b. Consumer Economics c. Demographic Economics d. Econometric, Statistical & Mathematical

Methods e. Economic Development Studies f. Economic Education g. Economic Fluctuations and Forecasting h. Economic Growth, Development and Planning,

Theory and Policy i. Economic History j. Economic Systems k. Economics of Technological Change

l. Energy Economics m. Environmental Economics n. General Economic Theory o. History of Economic Thought, Methodology p. International Finance q. International Investments & Aid r. International Trade Policy s. Labor Markets, Public Policy t. Law and Economics u. Marcoeconomics v. Manpower Training and Allocation w. Mathematical Economics x. Medical Economics y. Microeconomics z. Political Economics aa. Regional Economics bb. Resource Economics, Land Economics cc. Social Economics dd. Trade Unions, Collective Bargaining, Labor-

Management Relations ee. Urban Economics 44. HISTORY 45. INTERNATIONAL RELATIONS & POLITICAL

SCIENCE a. Comparative Politics b. Government c. Developmental Studies d. International Law & Organizations e. International Relations f. Political Philosophy g. Political Theory 46. LINGUISTICS & TRANSLATION STUDIES a. Anthropological Linguistics

b. Applied Linguistics c. Computational/Mathematical Linguistics d. Historical/Comparative Linguistics e. Linguistics Study of Specific Languages f. Morphology g. Phonetics/Phonology h. Semantics i. Theoretical Linguistics j. Technical Translation k. Interpretation l. Literary Translation & Translation Theory 47. LITERATURE & CREATIVE WRITING a. American Literature b. Classics c. Comparative Literature d. Feminist Literature e. English Literature f. Foreign Literature g. Pedagogy 48. PHILOSOPHY, RELIGION, AND THEOLOGY a. Aesthetics b. Ethics c. History of Philosophy d. Logic e. Metaphysics/Epistemology f. Philosophy of Languages g. Philosophy of Religion h. Philosophy of Science i. Philosophy of Social Science j. Social/Political Philosophy 49. PSYCHOLOGY a. Adolescence & Youth Psychology b. Applied Psychology

c. Behavioral Psychology d. Child Psychology e. Clinical Psychology f. Community Psychology g. Comparative Psychology h. Counseling Psychology i. Developmental Psychology j. Educational Psychology k. Environmental Psychology l. Experimental Psychology m. General Psychology n. Health Psychology o. Industrial Psychology p. Neuropsychology q. Organizational Psychology r. Personality Psychology s. Physiological Psychology t. Psyometrics u. School Psychology v. Social Psychology 50. SOCIOLOGY a. Comparative Sociology b. Environmental Sociology c. History of Sociology d. Industrial Sociology e. Medical Sociology f. Political Sociology g. Rural Sociology h. Sociology of Aging/Social Gerontology i. Sociology of Sex Roles j. Sociology of Work k. Urban Sociology 51. OTHER