2018 FOREIGN FULBRIGHT GRANT APPLICATION COVER SHEET

Name:
Family First Middle

PERMANENT ADDRESS:

EMAIL ADDRESS:

COUNTRY OF CURRENT CITIZENSHIP

COUNTRY OF BIRTH DATE OF BIRTH / / GENDER:

CURRENT OCCUPATION

MOST RECENT EMPLOYER:

FROM / TO /

ACADEMIC DEGREES

Degree Field of Study

SCHOLARSHIPS

TEACHING EXPERIENCE:
If you currently or previously held a language teaching position, please estimate how long you occupied the post.

Years Months Not Applicable

LANGUAGE SKILLS:
What language are you applying to teach/assist in the U.S.?

Plagiarism Agreement
 2018 FULBRIGHT PROGRAM
Application for foreign language teaching assistantship in the United States
General Information
1. APPLICANT NAME SUBMISSION: The first, middle and last (family) name provided on this application should be spelled
exactly as it appears in your passport. If you do not have a passport, you should submit the first, middle and last name spelling that
would likely appear on your passport.
Do you currently have a passport?
2. NAME (As it appears or will appear on your passport)
Last (Family) First Middle

Address all inquires about this candidate to: 3. PERMANENT MAILING ADDRESS:
Street
 Institute of International Education City
Fulbright Foreign Language Teaching Assistant (FLTA) Program
State (USA) State/Province
809 United Nations Plaza
(outside USA)
New York, NY 1001 Postal Code

E-mail: FLTA@iie.org Country

Telephone: ( )
E-mail:

4. DATE OF BIRTH: (Month/Day/Year) / / 5. CURRENT AGE

6. GENDER 7. BIRTHPLACE: (City, State/Province, Country)
8. COUNTRY OF CITIZENSHIP
State (if USA)

9. COUNTRY OF RESIDENCE State/Province (outside USA)

10. DO YOU NOW HAVE, OR HAVE YOU EVER HELD:

U.S. CITIZENSHIP?
U.S. DUAL CITIZENSHIP?
U.S. PERMANENT RESIDENCY?
DO YOU HAVE A VISA LOTTERY APPLICATION PENDING?
HAVE YOU EVER APPLIED FOR
U.S. PERMANENT RESIDENCY (i.e. green card)? My application was denied
My application is still pending

PLEASE SELECT ONLY ONE OF THE FOLLOWING REGARDING YOUR POSSIBLE ROLE ON A U.S.
UNIVERSITY CAMPUS
11. IN YOUR ROLE AS A LANGUAGE ASSISTANT ON A U.S. UNIVERSITY CAMPUS, YOU ARE WILLING TO:

12. IS THERE A PARTICULAR REGION IN THE U.S. THAT INTERESTS YOU?

13. IF THERE IS A SPECIFIC REGION THAT INTERESTS YOU, PLEASE INDICATE IT HERE. IF THERE IS NOT A
SPECIFIC REGION, PLEASE INSERT N/A. (APPLICANTS ARE NOT GUARANTEED PLACEMENT IN THE REGION INDICATED.)

14. IS THERE ANY COLLEGE OR UNIVERSITY TYPE FROM WHICH YOU WOULD REFUSE AN OFFER
ASSISTANTSHIP?
Single gender student Great ethnic diversity Requires specific coursework
Rural location Large
body on a credit basis
population
Urban location Offers coursework on an audit N/A, I would accept all
Small population Little ethnic
diversity basis
 Fulbright FLTA Program
Application
Plagiarism
Agreement

The FLTA Program seeks applicants that have developed a sense of personal integrity and are original thinkers. The
following application includes several opportunities to express your own thoughts, ideas, and opinions in essay
responses. Plagiarism in any of your answers to these questions will result in your disqualification from
participating in the FLTA program.

From the Oxford English Dictionary:

"Plagiarism is the wrongful appropriation or purloining and publication as one's own, of the ideas, or the expression of
the ideas of another"

Plagiarism will be understood to include any of the following:

Presenting wording, statistics or concepts as your own which should be attributed to someone else or to publications
(online or offline). This includes, but is not limited to:
o Copying the exact wording of a written source
o Presenting material with alterations in wording
o Paraphrasing the content of a source without citation

It is expected that your responses to essay questions in the following application will be your own work, and that use
of outside sources will be kept to a minimum. Applicants do not have to use secondary sources for essays. However,
any sources used in the construction of your responses must be cited.

By checking the box below, you are indicating that you understand both what actions constitute plagiarism in this
application, and the consequences resulting from any plagiarism found in your submission.

I have reviewed and understand the above information on the importance of presenting my own original work in
the Fulbright FLTA program application. I agree to properly cite any outside sources from which I take words or
ideas in the composition of my essay responses. I understand the consequences of plagiarism in my FLTA
application.
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15. Objectives: Completing the Objectives essay provides the readers (your home country contact, FLTA Program
staff and your future supervisor and other university/college officials) with a picture of you and your career interests. This
essay will allow you to:

Emphasize key qualifications, areas of expertise, skills and/or goals

Tip: Reflect on your overall qualifications and career goals: In what ways do they fit with the FLTA Program?
Help the readers find out about your character/personality
Tip: Think about making a good first impression
Appeal to college/university supervisor expectations
Tip: Consider: What qualifications are most desired by college and university professors in a language
teacher/assistant? What other personal qualities do you possess that would make you attractive to them? Think about
what role--or roles you expect to have on campus?

A good essay for this task will answer these questions:

1. Why are you applying for the FLTA Program?
2. What are your main qualifications?
3. What are your career goals?
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16. ACADEMIC INTERESTS: The FLTA Program is a non-degree program which offers coursework for enrichment
purposes. Select 2-3 areas of academic study that you feel would contribute to your development as a language professional.
Please note: the subjects you indicate are not guaranteed should you be selected for the FLTA Program. Topics you select
give you an opportunity to express your academic interests.
1.1.
2.
2.
Other
Other

17. NON-ACADEMIC INTERESTS: PLEASE LIST ANY NON-ACADEMIC INTERESTS (e.g. SPORTS,
MUSIC, ART, ETC.). INCLUDE INFORMATION ABOUT YOUR EXPERIENCE IN THESE AREAS.

18. ARE YOU PURSUING ANY OTHER SCHOLARSHIP, FELLOWSHIP OR EMPLOYMENT THAT WOULD
SUPERCEDE YOUR PARTICIPATION IN THE FLTA PROGRAM SHOULD IT BE OFFERED? PLEASE EXPLAIN:

19. DEGREE: PLEASE INDICATE THE LAST DEGREE YOU COMPLETED. PLEASE DO NOT LIST
CERTIFICATES IN THIS SECTION.

Degree Name (Masters, Bachelors) Field of Study

20. EDUCATION: LIST EDUCATIONAL INSTITUTIONS ATTENDED IN REVERSE CHRONOLOGICAL

ORDER, INCLUDING ANY IN WHICH YOU MAY BE PRESENTLY ENROLLED.

Name of Institution/Location Major Field of Study Dates (Month and year) Degree or Date Received
From To Diploma Name or Expected

/ / /

/ / /

/ / /

/ / /
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21. LIST SCHOLARSHIPS OR FELLOWSHIPS HELD AT PRESENT OR IN THE PAST. GIVE
SOURCE OR SPONSOR, AMOUNT, WHERE HELD, DURATION, AND YEAR.

22. INDICATE ACADEMIC HONORS OR PRIZES WHICH YOU HAVE RECEIVED.

23. OCCUPATIONAL EXPERIENCE:

IDENTIFY YOUR CURRENT POSITION OR OCCUPATION (Select the position title which best describes the activity
in which you are currently involved.)
If you selected Teacher as occupation, please specify the subject(s) you teach:
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LIST POSITIONS HELD (begin with most recent employment, if any.)
T
Name and address of Employer Type of Work (Position Held)
Reason for leaving Dates

/ /

/ /

/ /

24. TEACHING EXPERIENCE: IF YOU CURRENTLY OR PREVIOUSLY HELD A LANGUAGE TEACHING

POSITION, PLEASE ESTIMATE HOW LONG YOU OCCUPIED THE POST.
Years Months Not Applicable

25. 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.
26. IF YOU HAVE TRAVELED OR LIVED IN ANY COUNTRY OTHER THAN YOUR OWN, INDICATE
PLACES, DATES, AND REASONS.

27. LANGUAGE SKILLS: Please respond to all of the following fields.

What language are you applying to teach/assist in the U.S.?

Category Name of Language Proficient (Skill Level)

Host Country Language:

Mother Tongue:
Second Language:
Third Language:
 28. Examination Results:
Name of Exam Date Taken/To be Taken Score
TOEFL /
IELTS /

Other Test Taken Date Taken/To be Taken Score

/

29. Provide the name, address, and telephone number of individuals to be notified in case of emergency.

In Your Home Country In The United States

Family First
Family First
Street
Street
City
City
State/Province Postal Code State Postal Code
Country Telephone ( ) Country Telephone ( )

Email Email
List Below any close relatives or friends in the United States (name, address, and relationship)
Family First
Family First
Street
Street
City
City
State Postal Code State Postal Code
Country Telephone ( ) Country Telephone ( )

Email Email
Relationship Relationship
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30. TEACHING THE LANGUAGE OF NOMINATION: You may be asked to teach your own class. If so, what teaching
methodologies and techniques would you utilize to teach your language to U.S. students? This brief essay should focus on the language
you will be teaching in the U.S. (not English). Mention any innovative approaches you have utilized as a teacher or encountered as a
learner that you may employ.
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31. SHARING YOUR CULTURE: As a Fulbright FLTA you will act as a cultural ambassador of your country. What do you think it
means to be a cultural ambassador? Elaborate on your answer by selecting one of these scenarios and explaining how you would share
your culture. 1) A guest lecture at your host institution 2) An international festival3) Volunteering at a local youth center. Please do not
insert your actual CV or resume in this section.

This short essay should be your own unique ideas. It is recommended you keep quotations and the use of outside sources to a minimum.
However, if you decide to use quotes or information from an outside source, you must include a citation for each one utilized (this refers
to websites as well).
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32. Personal Statement: You should not copy your Objectives statement to this section. You should create a new essay.
You may include your curriculum vitae or resume. This essay will allow you to:

Tell a story
Tip: Consider: Whats special, unique, distinctive and impressive about your life story?

Present your life experience

Tip: Consider: Why might you be a better and more successful FLTA than others?

Help your future supervisor get to know you as a person

Tip: Consider: What personal characteristics do you possess?
Name: Country:

MARITAL STATUS:

Do you have dependents (individuals for whom you are financially responsible)? :

If you answered yes to dependents, how are they related to you (child, mother, father, spouse, etc.)?

Please note, the Fulbright FLTA Program does not provide J-2 visa sponsorship for dependents. Will you be able to participate in the program without
dependents? :

PLEASE DESCRIBE ANY PHYSICAL IMPAIRMENT YOU MAY HAVE. (This information is gathered for statistical purposes and to ensure appropriate
placement. The Fulbright Program does not discriminate on the basis of race, color, religion, sex, national origin, and/or physical impairment):

The Fulbright provided Accident and Sickness Program for Exchanges (ASPE) health benefit plan does not cover pre-existing conditions. If
you have a medical condition, you are encouraged to consult with your physician about how to manage care while in the U.S. and to consider
purchasing an international insurance plan.

HAVE YOU PARTICIPATED IN ANY OF THE U.S. GOVERNMENT SPONSORED PROGRAMS LISTED BELOW?
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 FULBRIGHT
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Biographic Information Sheet

Firs Name: Middle Name: Last Name:

Date of Birth (e.g. February 10, 2012): Gender:

Postal Address:

Permanent Address:

Permanent City: Province: Phone #:

Mobil #: Email ID: Pakistani National (Yes/No):

Academic Information
Proposed Field of Study:

Current Enrollment: Start Date: (mm/yyyy) End Date: (mm/yyyy)

Current Field of Study: Current Institution:

Current Degree CGPA/ %age:

Last Degree: Start Date: (mm/yyyy) End Date: (mm/yyyy)

Last Field of Study: Last Institution:

Last Degree CGPA/ %age:

Work Information
Current Position: Current Employer:

Total Years of Work Experience:

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CONFIDENTIAL LETTER OF REFERENCE

This letter of reference must be written by a teacher under whom the applicant has studied or by someone who
has supervised the applicant in work, athletics or other relevant activity. This letter must be in English. If not
in English, then an accurate translation must be attached.

Name of Applicant _________________________________Country _________________________

Name of Referee
__________________________________________________________________________________

1. How long have you known the applicant?

2. In what capacity have you known the applicant?

Teacher or Professor Employer or Job Supervisor

School Counselor Other (please specify) ____________

3. Please provide a candid evaluation of the applicants past performance and ability to pursue and successfully
complete a teaching assistantship in the United States. Your statement will be given considerable
importance by the American universities/colleges reviewing this application, and should, therefore, be as
complete and detailed as possible.

CONFIDENTIAL LETTER OF REFERENCE FOR __________________________________________(continued)

 FULBRIGHT
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4. In the rating chart below please evaluate the applicant in comparison with other students whom you have
known during your professional career.

Excellent Very Good Average Below Average

Creative
Motivation
Self-confidence
Independence, initiative
Intellectual ability
Academic achievement
Disciplined work habits
Adaptability to New Situations
Leadership Qualities
Potential for growth

5.Please indicate where the applicant would rank among students/employees currently or recently in your
department/organization.

95% 90% 75% 50% 25%

TOP BOTTOM

______________________________________________________________________________________________
____

Name and Title (print)

______________________________________________________________________________________________
____

School, Company or Organization

______________________________________________________________________________________________
____

Signature ________________________________________ Date ________________________________

Please return directly to the Selection Committee in the applicants home country. Under no circumstances should
the completed form be returned to the applicant.
 FULBRIGHT
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CONFIDENTIAL LETTER OF REFERENCE

This letter of reference must be written by a teacher under whom the applicant has studied or by someone who has
supervised the applicant in work, athletics or other relevant activity. This letter must be in English. If not in English,
then an accurate translation must be attached.

Name of Applicant ________________________________Country __________________________

Name of Referee
__________________________________________________________________________________

1. How long have you known the applicant?

2. In what capacity have you known the applicant?

Teacher or Professor Employer or Job Supervisor

School Counselor Other (please specify) ____________

3. Please provide a candid evaluation of the applicants past performance and ability to pursue and successfully
complete a teaching assistantship in the United States. Your statement will be given considerable
importance by the American universities/colleges reviewing this application, and should, therefore, be as
complete and detailed as possible.

CONFIDENTIAL LETTER OF REFERENCE FOR____________________________(continued)

 FULBRIGHT
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4. In the rating chart below please evaluate the applicant in comparison with other students whom you have
known during your professional career.

Excellent Very Good Average Below Average

Creative
Motivation
Self-confidence
Independence, initiative
Intellectual ability
Academic achievement
Disciplined work habits
Adaptability to New Situations
Leadership Qualities
Potential for growth

5.Please indicate where the applicant would rank among students/employees currently or recently in your
department/organization.

95% 90% 75% 50% 25%

TOP BOTTOM

______________________________________________________________________________________________
____

Name and Title (print)

______________________________________________________________________________________________
____

School, Company or Organization

______________________________________________________________________________________________
____

Signature ________________________________________ Date ________________________________

Please return directly to the Selection Committee in the applicants home country. Under no circumstances should
the completed form be returned to the applicant.
 FULBRIGHT
|f|l|t|a|

CONFIDENTIAL LETTER OF REFERENCE

This letter of reference must be written by a teacher under whom the applicant has studied or by someone who has
supervised the applicant in work, athletics or other relevant activity. This letter must be in English. If not in English,
then an accurate translation must be attached.

Name of Applicant ____________________________Country _______________________________

Name of Referee
__________________________________________________________________________________

1. How long have you known the applicant?

2. In what capacity have you known the applicant?

Teacher or Professor Employer or Job Supervisor

School Counselor Other (please specify) ____________

3. Please provide a candid evaluation of the applicants past performance and ability to pursue and successfully
complete a teaching assistantship in the United States. Your statement will be given considerable
importance by the American universities/colleges reviewing this application, and should, therefore, be as
complete and detailed as possible.

CONFIDENTIAL LETTER OF REFERENCE FOR ______________________________(continued)

 FULBRIGHT
|f|l|t|a|
4. In the rating chart below please evaluate the applicant in comparison with other students whom you have
known during your professional career.

Excellent Very Good Average Below Average

Creative
Motivation
Self-confidence
Independence, initiative
Intellectual ability
Academic achievement
Disciplined work habits
Adaptability to New Situations
Leadership Qualities
Potential for growth

5.Please indicate where the applicant would rank among students/employees currently or recently in your
department/organization.

95% 90% 75% 50% 25%

TOP BOTTOM

______________________________________________________________________________________________
____

Name and Title (print)

______________________________________________________________________________________________
____

School, Company or Organization

______________________________________________________________________________________________
____

Signature ________________________________________ Date ________________________________

Please return directly to the Selection Committee in the applicants home country. Under no circumstances should
the completed form be returned to the applicant.