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Ronald and Eileen Weiser Professional Development AwardsFor
Study and Research at the University of Michigan
2014 Application - For applicants from Armenia, Azerbaijan,
Belarus, Bosnia & Herzegovina,Georgia, Russia (Kaliningrad
District), Kazakhstan, Kosovo, Kyrgyzstan, Macedonia, Moldova,
Serbia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan.
Please complete and submit the following application by October
15, 2013 (for travel toUniversity of Michigan in March-April 2014
or September-November 2014).
All fields are required. To save, select Print and then choose
Adobe PDF.
Last Name: First Name:
Middle Name (if any): Gender: Male Female
Age: Date of Birth:
Citizenship: Country of Permanent Residence:
City of Birth: Country of Birth:
Home Address (including postcode):
Preferred Phone:
Preferred Email:
Alternate Email:
Current employer(s):
N am e of Inst itut ion(s) or Organiz ation(s)Current
position(s):
Professiona l Tit le a nd D epartme nt Affi l iat
ion(s)Specialization:
Current job responsibilities (continues on next page):
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Current Work Address (including postcode):
Work Phone:
Work Email (if different than above):
Institutions, NGOs, etc., with which you have cooperated in the
last three years (pleasespecify program names, locations, and
relevant dates):
English language ability (for each category below, list your
ability level as fluent, very good,good, fair, or beginner):
Speaking Reading Writing Listening
English
If selected as a Weiser Professional Development Fellow, I agree
to confirm my languageabilities in an interview:
Via telephone: Via Skype:
List previous educational experiences in English-speaking
countries (graduate or post-graduate studies, seminars, workshops,
conferences, etc.), locations, and dates:
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Title of research project:
Brief abstract of research project:
Name of faculty partner at the University of Michigan:
_______________________________
Length of desired stay: three weeks four weeks
Please indicate preferred month: March 2014 April 2014
September 2014 October 2014 November 2014
First choice: Second choice:
If you have been to the U.S. on a J-1 visa within the last two
years and are subject to the two-year return residency rule, please
indicate the exact dates of your last stay in the U.S.:
Please attach:1) Your CV.2) A copy of your doctoral diploma or
highest professional degree.3) A copy of your passport photo
page.4) A two-page personal statement describing: a) the research
or collaborative projectyou plan to pursue at the University of
Michigan, b) your reason for applying for thisopportunity and how
this opportunity will benefit your home institution.5) An
invitation from the University of Michigan school, department,
and/or facultypartner with whom the research will be conducted;
email invitation is acceptable.6) One letter of recommendation from
the rector or dean at your institution should besubmitted in a
sealed envelope, or sent separately to Polsko-Amerykaska
KomisjaFulbrighta, ul. K.I. Gaczyskiego 4, 00-362 Warszawa,
Poland.7) If you have taken the TOEFL exam in the last three years,
attach a copy of your score
report.
Submit by email to:[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]
