FULBRIGHT-SENESCYT 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.)

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1. NAME OF APPLICANT Mr. Ms. Family First Middle Initial

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

. 3. PERMANENT ADDRESS: 4. HOME PHONE:

5. DATE OF BIRTH: (Month-Day-Year) 9. BIRTHPLACE: (City, State/Province, Country)

6. GENDER: Male Female

7. OFFICE PHONE: 8. EMAIL:

10. COUNTRY OF RESIDENCE: 12. AGES OF CHILDREN, IF ANY:

11. MARITAL STATUS: (Single, Married, Divorced, Separated, Widow, Widower, etc.) 13. CITIZENSHIP:

13.a

DO YOU NOW HAVE, OR HAVE YOU EVER HELD: U.S. CITIZENSHIP? DUAL CITIZENSHIP? U.S. PERMANENT RESIDENCY? Yes Yes Yes No No No

13.b HAVE YOU EVER APPLIED FOR A U.S. VISA? IF YES, WHEN?

Yes

No Yes No No IF YES, WHAT TYPE OF VISA?

WAS THE VISA GRANTED? Yes

DO YOU HAVE IMMEDIATE RELATIVES IN THE U.S.?

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:

Masters

Doctorate

EXAMINATION RESULTS
16. EXAMINATION DATES AND TEST SCORES: (Date if taken or future date for taking exams (Month/Year))
Date Score Percentile Date GRE General Exam Date GRE Subject Exam Verbal Score % Quantitative Score % Analytical Score %

TOEFL TSE TWE GMAT IELTS

Score

Subject Name

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)

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.)

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NAME OF APPLICANT:
24.

COUNTRY:

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.

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NAME OF APPLICANT:
25.

COUNTRY:

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.

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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 READING WRITING SPEAKING

LANGUAGE 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 30. PLEASE LIST ANY CLOSE RELATIVES OR NOTIFIED IN CASE OF AN EMERGENCY: FRIENDS 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 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:

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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: NAME OF REFEREE: TITLE COUNTRY:

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 reviewing this students 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.

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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 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 Very Good Average Below Average

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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