Request a Fulbright Senior Specialist

Application for Host Institutions

(Please note: Host institution is required to provide
lodging accommodation, meals and incidental
expenses/M&IE, and local transportation
to the Fulbright Senior Specialist for the duration of the
grant period.)
This form is for the use of academic institution that wish to request a Fulbright Senior
Specialist. Please return the completed form to The Executive Director, Fulbright Indonesia,
American Indonesian Exchange Foundation, Gedung Balai Pustaka Lt. 6, Jl. Gunung Sahari
Raya No. 4, Jakarta 10720. You can also fax the form to (021) 3452050 or send it as an e-
mail attachment to rfadillah@aminef.or.id.

Instructions to potential host institutions. The recruitment effort for your program request
can be most effective if:
1. Careful attention is given to the Project description, purpose, impact on host institution,
potential for institutional linkages to ensure adequate detail in describing the scope of
work.
2. Adequate lead time is given for recruitment of specialists who best fit the program
request.
3. Flexibility in the time frame of the proposed project is allowed for in order to
accommodate the various schedule of potential Fulbright Senior Specialist candidates.

PROGRAM INFORMATION

Field Requested Primary Fields

(Choose only one primary fields. Anthropology Archaeology
For U.S. Studies, please also specify Business Administration
Communications/Journalism
one sub-field.) Economics Education
Environmental Science Information Technology
Law Library Science
Political Science Public Administration
Sociology Social Work
Agriculture Applied Linguistics/TEFL
Urban Planning Public/Global
Health
Peace and Conflict Resolution Studies
U.S. Studies - GENERAL U.S. Studies - Art

U.S. Studies - Art History U.S. Studies - Dance

U.S. Studies - History U.S. Studies -
Literature
U.S. Studies - Music U.S. Studies - Popular
Culture
U.S. Studies - Religious Studies U.S. Studies -
Theater
U.S. Studies - Women’s Studies
Specialization desired within the field
requested: _________________________________________________________

Type of Activity Requested Present lectures at graduate and undergraduate levels

Participate in or lead seminars or workshops at overseas academic institutions
Conduct needs assessments, surveys, institutional or programmatic research
Take part in specialized academic programs and conferences
Consult with administrators & instructors of post-secondary institutions on
faculty development
Develop and/or assess academic curricula or educational materials
Conduct teacher-training programs at the tertiary level
Other (please describe):
___________________________________________________________

Name of Institution Hosting the

Award:

City:
Contact Person/Title:
Telephone Number/HP:
E-mail Address
Web Address:

Project Description:
(In order to provide the best possible
matches of specialists with program requests,
please be
very specific as to the type of and scope of
work that the
specialist would engage in.) Attach additional
sheet if
necessary.

Project Purpose:
(Describe the program objectives and provide
Background on th eissues an d institutions
involved.)
(not more than 500 words)

Project impact on host institution:

Please comment
on the project’s potential impact on the host
institution. Not more than 500 words.

Project potential for institutional

linkages:
(Please describe project’s potential for
developing
institutional linkages between host
institution and grantee’s home institution.)
(not more than 500 words)

Length of Grant: (Grant Length may be from (days)

2-6 weeks.)

Proposed Starting Date:

(Please advise the date and time of the
program
In local time)

Preferred Arrival Date:

Number of Program Days Requested:

Flexibility of time frame. Providing

flexibility in the
time frame of the requested project may result
in a
broader pool of candidates from which to
choose.
Please describe the extent (in days or month)
of the host institution’s flexibility
Contact Information for Person
Responsible for lodging
Arrangements:

Name:
Professional Title:
Telephone Number/HP:
E-mail Address

Lodging Arrangements
Describe the lodging arrangements that have been made
for the Specialist (lodging for the duration of the stay
should be arranged ahead pf arriva). If in-kind
coverage of cost share, please descrbe.
If monies will be paid directly to the grantee,
please indicate the amount.

Estimated US Dollar amount

Lodging is available: from start date
(mm/dd/yyyy)
To End date: (mm/dd/yyyy)

Meals Arrangements
Describe arrangements for coverage of meals.
If in-kind coverage of cost share, please descrbe.
If monies will be paid directly to the grantee,
please indicate the amount.

Estimated US Dollar amount

SPECIALIST DESCRIPTION
Type of Specialist Required (check one) Academic Professional Either
QUALIFICATION PREFERRED
Degree:
Minimum years of teaching experience:
Academic rank preferred:
Language requirements:

Audience(s) (One way of determining the

level of grantee
expertise needed for a program is to know with
whom
he/she will be working. If the name of the
audience does
not make clear their level of sophistication,
please
elaborate).

Other:
If this is a request for a specific individual (Name Request), please provide as much of the
following as possible: Note: Host institutions may list specific individuals in whom the institution is
particularly interested and may invite such candidates to apply with the understanding that the
invitation does not constitute a commitment or a preference in final consideration.

Name of Person Requested (Note: the

requested
individual must be a U.S. citizen):
Title of Person Requested:
Institution:
Department (if applicable):
Address:
Telephone Number(s):
Fax Numbers:
E-mail Address(es):
Provide a brief justification for requesting
this person: