Form DS-4502 Application for Teaching and Administrative Exchanges an

Fulbright Teacher Exchange Program Application Package

DS4502

Fulbright Application for Teaching and Administrative Exchanges and Seminars Abroad

OMB: 1405-0114

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Fulbright Teacher Exchange Program Application and Instructions
Applicants are strongly encouraged to apply on-line at www.fulbrightexchanges.org. If you choose to apply using the paper application,
please read our website (www.fulbrightexchanges.org) carefully before completing the application. Be sure that you meet eligibility
requirements for the program as well as the specific requirements of each country and type of exchange for which you apply. The
application forms may be photocopied for interested colleagues, and applications may be submitted on photocopied forms; however,
applications must bear original signatures.
Applications are not considered until all of the forms listed on the "Application Checklist" (Page Ai) are completed properly and received by
the Fulbright Teacher Exchange Program.
Those applying for teaching and administrative exchanges, and summer seminars should complete pages Aii - A5 of the application and
sign the terms of agreement on page A7. All forms and recommendations on the checklist must be submitted by the October 15
deadline.
Applicants for special short programs should complete only pages Aii and sections, I, II, IV, V, VI, VII, IX, X and XIII of the application and
submit by the special program's deadline.

Mailing Address
Applications, references, related documentation, and all future communication should be sent to:
Fulbright Teacher Exchange Program
600 Maryland Avenue, SW, Suite 320
Washington, DC 20024-2520
[email protected]
202.314.3520

Special Instructions:
J. William Fulbright Foreign Scholarship Form
This page, Aii, follows the Application Checklist page. It must be completed and returned along with your application. In section L, you
should provide a brief description of what you expect to gain professionally and personally from participation in the Program. This form
MUST be typed.
"Interview Sites"
Select two cities from page Aiii of the booklet and indicate their code numbers and city names on page A1 of the application. Interview
dates are set by the interview committee chairperson for each site. You will be informed of the site and date of the interview for which you
have been scheduled (most applicants are scheduled for an interview at their first choice site). You are responsible for attending the
interview on the scheduled date.
Application (pp. A1 to A7)
While typing is preferred, application forms may be completed in black or blue ink. If additional space is needed, enter information in Item
XIV, "Remarks," or use additional sheets. Place your name and date of birth at the top of each additional sheet, and identify the item
number to which the answer applies. Fill out the application forms completely; use additional sheets for continuation purposes only.
Do not send your résumé or simply say "see attached."
Sign page A7 and forward the original of pages A1 through A7 (and any additional sheets), along with the original of the essay to the
Fulbright Teacher Exchange Program.
I. "Applicant Basic Data" (p. A1)
For Question E, indicate the academic year(s) for which you applied, whether or not you received an exchange or seminar grant that year.
Please note that Questions I and J, "Ethnicity/Race" are optional and are collected for statistical purposes only.

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Instruction page 1 of 3

II. "Application For..." (p. A1)
Before choosing a country for an exchange or seminar, be sure to read the eligibility requirements for that country's program on the
Teacher Exchanges & Summer Seminars section of our website.
List your country choices in order of preference. Do not request more than one country on each line except in the case of the United
Kingdom, where England, Scotland, Northern Ireland or Wales may be listed in order of preference on the same line.
Unless you answer "No" to Question D, you will be considered for any country for which you are eligible.
If you answer "Yes" to Question E you will be considered for a one-way assignment should a suitable assignment become available.
One-way assignments are very rare and up to five per year may be available depending on funding and interest by a particular country.
A U.S. applicant may not apply directly for a one-way assignment.
III. "Modern Foreign Language Fluency" (p. A2)
Indicate your proficiency in languages other than English. You will be screened for verbal proficiency if:
• you teach French, German or Spanish;
• languages are required for countries you select;
• languages you list are spoken in participating countries, and you rate yourself "good" or "excellent."

V. "Present Employment" (p. A2)
The approving administrative official listed under Question E must be the same as the person completing the "Administrative Approval for
Applicant" form (Page A11).
VI. "Daily Schedule for Current Year" (p. A3)
To enable accurate matching, teachers are asked to describe fully their current teaching assignments. Please write this directly on the
application, using an additional sheet for continuation purposes only.
X. "School or College Information" (p. A5)
Information on the schools of applicants is critical to finding suitable matches. This section should be filled out thoughtfully and completely.
Use additional sheets if necessary.
XI. "Accommodations" (p. A5)
Please answer all questions if you wish to exchange housing. Note: Housing is a private matter between grantees in which the United
States Department of State will not become involved. For direct exchanges, teachers are expected to locate suitable housing for their
partner and vice-versa before going on exchange. Fulbright recommends the following options when making housing determinations: 1)
finding housing on your own in the open market with suggestions from your exchange partner; 2) asking your exchange partner to locate
local, in-country rental options that might meet your needs; 3) exchanging housing with your partner. The Fulbright program reserves the
right to request termination of an exchange should housing issues significantly affect how the professional exchange is conducted. Any
problems arising from a housing situation into which an individual grantee has entered are the sole responsibility of the grantee and not of
the Fulbright program.
Application (pp. A11 to A17)
Pages A11 to A17 are approval and reference forms. The applicant should complete Item 1 on each form and then give them to the
appropriate colleagues or officials. All four of these forms must be submitted with your application. These forms must be filled out
completely, and not simply signed. Include them in your application package in sealed envelopes signed across the back of the envelope
flap. If your school district requires the Administrative Approval form to be sent under separate cover, indicate this on the "Application
Checklist."

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Instruction page 2 of 3

"Administrative Approval for Applicant" (p. A11)
Administrative Approval forms (p. A11) are due by October 15, 2008. The official who completes and signs the "Administrative
Approval for Applicant" form must be the official authorized to approve participation in the exchange, grant a leave of absence, and
approve the appropriate salary arrangements. (For year and semester programs, the "with salary" box must be checked, or the
application will not be considered. For short term programs occurring during the school year, we recommend that approval be
given "with salary." If the "with salary" box is not checked, the applicant must explain on a separate sheet how she or he will
fund participation. For summer seminars "without salary" is appropriate. For one-way assignments, either selection is
appropriate) Within public school systems, administrative approval must come from the district level (e.g. usually the superintendent). If
the approval is pending board confirmation after October 15, 2008, please notify the Fulbright Program in writing at the above address.

The administrative approval form may be submitted in a sealed envelope signed across the back by the administrator. It may be submitted
separately or as part of the application, but it must be sent no later than October 15, 2008. However it is submitted, applicants are strongly
encouraged to discuss their application to the program with their administrator in advance of applying and should be aware that their
application will not be considered without receipt of this approval. Applicants who do not file an administrative approval form in a timely
manner or whose administrator has denied approval will be informed of this omission or denial by letter.
Reference Forms (pp. A13, A15 and A17)
All reference forms are due by October 15, 2008. The references should be completed and signed by individuals familiar with the
applicant's professional work. One of these forms (the "Immediate Supervisor Reference for Applicant") must be completed by the
applicant's immediate supervisor or the person responsible for the applicant's formal evaluation. The Supervisor must also provide a
general description of the school on the reverse of this form. Persons writing references should place the reference form in a sealed
envelope signed across the back and clearly marked "Reference for (applicant's name)." Sealed and signed references must be included
in your application package. Applicants should not include performance evaluations with their applications. Other commendations and
awards may be listed in Item VII, Question D, on Page A3.
In general, we prefer that the entire application packet (including application, essay, references) be submitted to our office in one
complete packet when possible.
Miscellaneous
Applicants must inform the Fulbright Teacher Exchange Program in writing of:
•
•
•
•
•
•

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a change of address or phone number;
a change of plans affecting the application;
a desire to withdraw the application;
an application to teach or study abroad under another program;
a termination of teaching contract;
a change in assignment or school administration.

Instruction page 3 of 3

TEACHER
EXCHANGE PROGRAM
APPLICATION SECTION
2009-2010
We encourage all applicants to use the online application form when
applying for the Fulbright Teacher Exchange Program. The online version
of the form is easily submitted, and applicants can more readily update
their information if they re-submit their application to the program in
subsequent years.
To access the online application, please go to the Fulbright Teacher
Exchange Program web-site: www.fulbrightexchanges.org
Special instructions for filling out the online application form may be
downloaded from the web-site prior to beginning the online form.

Application Checklist
Please complete this checklist and enclose it with your application package. Please do not staple any of your application pages
(paper clips may be used). Mail all application materials to:
United States Department of State
Fulbright Teacher Exchange Program

The application deadline is

600 Maryland Avenue, S.W.; Suite 320

October 15, 2008

Washington, DC 20024
1.

Does your package include:
a. 1 Fulbright Foreign Scholarship Board (FSB) form?

Yes

b. 1 original of the application?

Yes

c. 1 original of the essay?

Yes

d. 1 "Administrative Approval for Applicant" form?*

Yes

e. 1 "Immediate Supervisor Reference for Applicant" form?*

Yes

b. Are you currently employed at the specified teaching level?

Yes
Yes

No
No

c. Are you currently employed in the specified subject field?

Yes

(The FSB form must be typed. Handwritten copies will not be accepted.)

f. 2 additional references?*
[Please do not send resumes, audio or video tapes.]
2.

Are any of the above documents being sent under separate cover?
If so, which ones?

Is your Administrative Approval completed by the school official authorized
to grant the required salary and leave arrangements?
Make sure you are eligible for all the positions in the countries you listed in Section II
of your application:
a. Are you fluent in the required languages?

*All references forms submitted must include original signatures. The reference forms may be included with your application as
a complete package. However, if a reference must be mailed under separate cover it must be also submitted by the October 15
deadline.
PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average two (2) hours
per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. This information is being collected to evaluate a candidate's
eligibility and suitability to be matched with a foreign counterpart for the Fulbright Teacher Exchange Program. Responses are
voluntary; however, insufficient applicant data could disable successful matching. A federal agency may not conduct or sponsor,
and the respondent is not required to respond to, a collection of information unless it displays a valid OMB control number. Send
documents regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to A/ISS/DIR, U.S. Department of State, Washington, DC 20520.

PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Section 102 of the Mutual Educational and Cultural Exchange Act of 1961,
as amended (the Fulbright-Hays Act) (22 U.S.C. 2452).
PURPOSE: The information solicited on this form is necessary to evaluate a candidate's eligibility and suitability for participation in
the Fulbright Teacher Exchange Program, for general statistical use within the Department of State, and to direct program outreach
strategies in subsequent program cycles. Failure to provide the information requested on this form may result in non-selection.
ROUTINE USES: The information may be shared with overseas counterpart agencies of the Bureau of Educational and Cultural
Affairs or field personnel in selected countries to ensure matching with a foreign counterpart, and with local school authorities for
their concurrence on the exchange. The information provided may also be released to federal, state, local, or foreign government
entities for law enforcement purposes.

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Page Ai

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

J. William Fulbright Foreign Scholarship Board
Fulbright Teacher Exchange Candidate
2009-2010
Last

A. Name:
Dr.

Mr.

Mrs.

B. U.S. Citizen:

Middle Initial

Miss

Ms.
Yes

First

C. Home Telephone (area code, number)

If no, state country of citizenship

(

Country of residence

)

D. Complete Home Mailing Address (include number, street, city, zip code):

F. Indicate year and country of any previous
Fulbright grants (if none, write "none"):

E. Date of Birth (mm-dd-yyyy):
Place of Birth (city, state, country):
G. Current Occupation:
Name and address of employer

Job Title

Employed Since (mm-yyyy)

H. Current Subject(s) and level(s):

I. First Country Choice:

J. Education:
Name of institution, university, or professional school and location

Major field of study

Name of degree and date (mm-yyyy) received

K. Name your most significant publications/honors/awards/project or other accomplishments:

L. Provide a synopsis in approximately 50 words of your personal goals as related to this exchange program. The explanation of your goals will
be reviewed by the Fulbright Scholarship Board.
(Please use only this space. Additional pages will not be accepted):

FOR FSB USE ONLY:

Approve
FSB Name

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xx-xxxx

Disapprove
Signature

Abstain
Date (mm-dd-yyyy)

Page Aii

Interview Committee Sites
ALABAMA
1 Auburn
ALASKA
2 Anchorage
ARIZONA
3
4

Tempe
Tucson

ARKANSAS
5

Little Rock

CALIFORNIA
6
7

Irvine
Fullerton

Sacramento

9 San Diego
10 San Francisco
COLORADO
11 Denver
CONNECTICUT
12 New Britain
DISTRICT OF COLUMBIA
13 Washington
FLORIDA
14 Gainesville
15 Miami
GEORGIA
16 Kennesaw
HAWAII
17 Honolulu
IDAHO
18 Boise
ILLINOIS
19 Chicago

LOUISIANA
24 Baton Rouge
MAINE
25 Westbrook
MARYLAND
26 Baltimore
MASSACHUSETTS
27 Marlborough
MICHIGAN
28 Farmington
29 Traverse City

21 Des Moines
KANSAS
22 Wichita
KENTUCKY
23 Louisville

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OREGON
48 Portland
PENNSYLVANIA
49 Harrisburg
50 Philadelphia
51 Pittsburgh
PUERTO RICO
52 Hato Rey
SOUTH CAROLINA
53 Columbia

30 Minneapolis

SOUTH DAKOTA
54 Sioux Falls

MISSISSIPPI
31 Jackson

TENNESSEE
55 Nashville

MISSOURI
32 Kansas City
33 St. Louis
MONTANA
34 Missoula
NEBRASKA

TEXAS
56 Corpus Christi
57 Dallas
58 El Paso
59 Houston
60 Lubbock
61 San Antonio

35 Omaha
UTAH
NEW HAMPSHIRE

62 Ogden

36 Keene
VERMONT
NEW JERSEY

41 Essex Junction

37 Piscataway
VIRGIN ISLANDS
NEW MEXICO

63 St. Croix

38 Albuquerque
VIRGINIA
NEW YORK

64 Roanoke

39 Hempstead
42 Syracuse

20 Indianapolis
IOWA

47 Oklahoma City

MINNESOTA

40 New York City
INDIANA

OKLAHOMA

NORTH CAROLINA
43 Charlotte
NORTH DAKOTA
44 Jamestown
OHIO
45 Cincinnati

WASHINGTON
65 Seattle
66 Spokane
WEST VIRGINIA
67 Institute
WISCONSIN
68 Madison
WYOMING
69 Casper

46 Cleveland
Page Aiii

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

U.S. Department of State

APPLICATION FOR TEACHING AND ADMINISTRATIVE EXCHANGES AND SEMINARS ABROAD
Please read all instructions before completing this form. Please type or print clearly in black ink. This form may be copied.
ID#:09

First Choice
Interview Site Number:

Second Choice
Interview Site Number:

City:

I. APPLICANT BASIC DATA
Name (Last, First, Middle):

A. Title:
Dr.

Mr.

Ms.

Miss

F. U.S. Citizen:

Yes

G. U.S. Veteran:

Yes

H. Disabled:

Yes

Mrs.

B. Complete Home Mailing Address (include number, street, city, state, zip code):

If so, please describe:

C. Home Telephone (area code, number):
Home Fax (area code, number):

(

(
)

)

I. Ethnicity: (select one)

Hispanic or Latino

Not Hispanic or Latino

Home E-Mail:

J. Race: (select one or more of the
following)
American Indian or Alaskan
Native

D. Date of Birth (mm-dd-yyyy):

Asian

E. Have you ever applied to the program before?
If so, list all program years for which you applied (e.g., 1989-90, 1998-99):

Black or African American
Native Hawaiian or Other Pacific
Islander
White

II. APPLICATION FOR:
You may check more than one box.
year-long exchange

semester exchange

six week exchange

summer seminar

short program*

*please refer to any special announcements for information about these programs.
A. Teaching Position:
List countries in order of preference.

Yes

1.
2.
3.

B. Administrative Exchange:
List countries in order of preference.
1.

Yes

C. Summer Seminar Abroad:
List countries in order of preference.
1.

D. Would you consider placement in countries other than those you've listed ?

Yes

E. Would you consider a one-way assignment ?

Yes

F. Is your spouse applying for a position abroad through this program ?

Yes

1. If so, will you accept a position if no position is offered to your spouse ?

Yes

2. Are you and your spouse willing to be placed in different locations ?

Yes

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Page A 1

III. MODERN FOREIGN LANGUAGE FLUENCY (Applicants for seminar only need not complete this section.)
Language

Understanding
Exc.

Good

Speaking
Fair

Exc.

Good

Reading
Fair

Exc.

Good

Writing
Fair

Exc.

Good

Fair

IV. EDUCATION AND PROFESSIONAL PREPARATION ABOVE SECONDARY SCHOOL (List degrees in

chronological order.)

Dates Attended
(mm-yyyy)

Institution, Location
From

Degrees Received
To

Kind

Major Subjects

Date
(mm-yyyy)

V. PRESENT EMPLOYMENT
A. Present Position Title:

In Present Position From (mm-yyyy)

B. Name and Address of School (include number, street, city, state, zip code):

Telephone (area code, number) and e-mail address:

Fax (area code, number)

(

)

C. School Principal's or College Dean's Name (include Dr., Mr., Mrs., Ms., or Miss):

School Principal's or College Dean's Title:

Telephone (area code, number) and e-mail address:

D. Immediate Supervisor's Name (include Dr., Mrs., Ms., or Miss):

Immediate Supervisor's Job Title:

Telephone (area code, number) and e-mail address:

E. Approving Administrative Official's Name (include Dr., Mr., Mrs., Ms., or Miss):
Note: Must be the official authorized to approve participation in the exchange, grant a leave of absence, and approve the appropriate
salary arrangements, e.g., President, Headmaster, Superintendent or District Official. See "Administrative Approval for Applicant" form.

Approving Administrative Official's Job Title:

Telephone (area code, number) and e-mail address:

Name and Address of Approving Administrative Official's Institution (include number, street, city, state, zip code):

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Page A 2

VI. DAILY SCHEDULE FOR CURRENT YEAR (Administrator Exchange Applicants describe duties on separate sheet.)
A. Subjects: Be specific and provide details (e.g., World
History: European emphasis). Special Education teachers
are requested to include details about student needs and
teaching approaches.

Number of
Teaching
Hours Per
Week

B. Additional Activities: Describe workload other than a
teaching position (e.g., counseling, supervision, curriculum
development extra-curricular activities).

Number of
Teaching
Hours Per
Week

Grade Level and Age of Students
Grade

Age

Grade Level and Age of Students
Grade

Age

Number of
Students

C. What is the best time to call you at school ?
D. Have you been absent more than six days per year in the last three years ?
If yes, please explain:

Yes

VII. PREVIOUS EXPERIENCE/EMPLOYMENT
A. List any full-time teaching/administrative experience, beginning with the most recent:
Dates
Name and Location
Position Title
To
From

Full-Time Teaching Position
Grade

Subject

B. List any experiences you have had studying, working or traveling abroad:
Dates
(mm-yyyy)
From

Country

Purpose of Visit

C. List memberships in educational, professional, and civic associations:

D. List awards and publications:

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Page A 3

VIII. OTHER EXPERIENCE (Applicants for seminar only need not complete this section.)
A. List extracurricular activities you can direct or sponsor (e.g., sports, arts, dramatics, music, etc.):

B. List educational experiences you have had which would be especially helpful to you in working abroad (e.g., working with bilingual
students, student exchange programs, etc.):

C. List experiences you have had in teaching English to non-native speakers:

IX. U.S. GOVERNMENT EDUCATIONAL EXCHANGE GRANTS
A. Have you ever received a U.S. Government educational exchange grant ?
If yes, please indicate the year, country, type of grant and sponsoring agency.

Yes

B. If you did not accept or complete the grant, explain briefly:

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Page A 4

X. SCHOOL OR COLLEGE INFORMATION
A. If school is primary or secondary, is it year-round?

B. Dates of current school year terms (mm-dd-yyyy): Fall (from:
C. Number of school teaching staff:
D. School type:

Public

Number of terms:

Yes

) Spring (from:

to:

Number of faculty in department:
Private

Number of students in institution:

E. School location:

Religious

)

Urban

Suburban

Rural

F. Description of school/college (include academic level, composition of student body, teaching method, resource materials, special
features, etc.). Use additional sheet if necessary:

XI. ACCOMMODATIONS (Applicants for seminars, short programs and administrative exchanges need not complete this section.)
A. HOUSEHOLD MEMBERS (other than applicant):
Relationship
Code
H: Husband
W: Wife
D: Daughter
S: Son
O: Other

Names

Dates of birth
of dependents
21 and below
(mm-dd-yyyy)

To accompany on teaching
assignment (Check One)

Yes

B. HOUSING:
Are you willing to exchange housing?
If yes, type of accommodation

Yes
House

Number of rooms:
Housing location:

Apartment

Proximity to School (miles):
Other (Describe):
Number of beds:

Number of bedrooms:
Urban

Suburban

Rural

Is adequate public transportation available in the community?

Yes

Does it run between your home and your school?

Yes

Do daily tasks in your community require use of a car, e.g., grocery shopping, doctor visits, etc.?

Yes

XII. ESSAY
On no more than two additional pages, please write one essay addressing both A and B below:
A. Provide a narrative picture of yourself. The essay should deal with your personal history, focusing on influences on your intellectual
development, the educational and cultural opportunities (or lack of them) to which you have been exposed, and the ways in which these
experiences have affected you. Also include your special interests and abilities.
B. Describe your future career goals and plans, especially ways you plan to use your experience abroad in your professional work in this
country and to enhance international education in your school/college and community.

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Page A 5

XIII. SHORT PROGRAMS
(Only applicants applying for special short programs need to complete this section.)
A. Name the short program to which you are applying.

B. Specify the dates of short program.

C. Describe briefly any U.S. professional career experience that you feel qualifies you to participate in the short program to which you are
applying.

D. Note any other professional development or training you have received that would qualify you for this short program.

E. If the short program involves electronic follow-up with students or partners in another country, describe how you currently integrate
web-based technologies or other distance-learning techniques in your lesson planning and classroom discussions.

F. Have you written papers, conducted research, or made presentations at a conference related to the topic of this short program ?

G. If the short program involves teacher training, describe any teacher training experience you have had, either in the U.S. or abroad.

H. List any professional associations to which you belong that are relevant to the short program.

I. Write a brief description (limit 1 page) of your interest in the short program to which you are applying. Describe in detail why you feel
you would contribute to the program and what benefit the program would bring to you, your school, and your students.
Give an idea of the resources in your community that you would call upon to help you carry out this program.

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Page A 6

XIV. REMARKS
(Additional space for answers: Use this space to provide additional information on any item. Write the number
and letter of the item to which each answer applies. If you need more space, attach additional sheets.)

TERMS OF AGREEMENT IF SELECTED
1.

I agree to reflect the ideals of the United States of America while observing and obeying the laws of the country in which I will
be exchanging.

For teacher exchange applicants: When requested, I will have a complete physical examination and will submit a physician's
"Report of Medical Examination." I will also submit a "Statement of Health for Dependents" form from a physician for all who
accompany me. All medical examinations will be at my expense. In addition, I guarantee that I and anyone accompanying me
will have comprehensive medical insurance sufficient to cover any major medical contingency which may occur while abroad.
For seminar and administrative exchange applicants: When requested, I will submit a statement of health from a physician. I
understand that a medical examination report, completed at my expense, may be required.

I am aware that travel before a grant is awarded is not reimbursable.

If required by my grant, I will travel on an airline designated for the transportation of United States grantees.

I will attend all orientation activities in the United States or abroad.

If selected for a teaching assignment abroad, I will complete my assignment in the country to which I am assigned, remaining, if
necessary, beyond the usual closing date in the United States. I will return to my teaching post in the United States for the
year following my exchange year unless an extension of my leave is authorized by my school authority.
If selected for a short-term assignment of eight weeks or less, I will complete it, participate in all activities, and complete all
required assignments. I will not be accompanied by dependents, relatives, or friends until the termination of the short-term
assignment.

7. I will accept no employment other than my position as an exchange teacher during my stay abroad, unless approved in writing
by the administering foundation, commission, or embassy.
8. I am aware that, should the exchange be terminated as a result of my inability to fulfill the obligations, I may be asked to
reimburse funds expended on my exchange.
9. I am aware that no one or more of the following will be liable for any claim or claims resulting from either exchange partners'
failure to enter upon or to complete the program outlined in the grant: the FSB, the United States Department of State, the
cooperating agency, and the commission or post.
10. I have had a criminal background check conducted by my institutional/district at the time of my employment.
Please list date of most recent criminal background check (mm-dd-yyyy)
I certify that I have read and understand the "Terms of Agreement" and that the information provided in this application is, to the
best of my knowledge, true and correct. I am aware that a false statement may be grounds for non-selection or termination of my
exchange. I further certify that I have notified the Teacher Exchange Branch of any misdemeanor (except minor traffic violation) or
felony convictions or pending indictments. My signature confirms that I will abide by the "Terms of Agreement" if selected for
program participation.

Date (mm-dd-yyyy)

Signature of Applicant

How did you first hear about the Fulbright Teacher Exchange Program?
from a colleague at my school or college

through a professional journal or other publication

from a school or college administrator

at my local library

from a former participant of this program

through a mailing from the Fulbright program

from a friend

other (please specify)

at a conference

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Page A 7

Blank sheet

TEACHER
EXCHANGE PROGRAM
REFERENCES
2009-2010

Blank sheet

Administrative Approval for Applicant

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

ID#:09

1. Name of Applicant (Last, First, Middle):
2. INSTRUCTIONS FOR APPROVING ADMINISTRATOR:
Please complete the following sections and sign this form to certify your approval or disapproval of the applicant's pursuit of an
exchange, one-way assignment, or seminar opportunity through the Fulbright Teacher Exchange Program. Indicate the type of leave to
be granted and whether or not your teacher has undergone a criminal background check (You may check more than one box). We
strongly encourage applicants and administrators to consult before completing this form. (Please see reverse of this form.)

A. APPROVAL
For Direct Exchanges (one year, one semester, short-term) and Administrative Exchanges:
The above applicant is employed full-time by our college, school or school system. The applicant has, in my judgment, superior
qualifications and will be an excellent representative of American education abroad. If we and all other necessary parties agree
to a proposed assignment, the following leave(s) of absence will be approved and the applicant will be released under the
conditions checked below in order to accept a position under the Fulbright Teacher Exchange Program. ("With Salary" is required
for applicants of direct exchanges of one year or one semester.)

With salary

Without salary

Summer Seminars: Either no leave of absence is required, or the teacher will be given, with or without pay, the leave of absence
required for participation in the Seminar.

With salary

Without salary

For One-Way Assignments (one year, one semester, short-term):
If a one-way assignment were to become available and the above applicant were to be proposed for such an assignment
and all necessary parties agree to the proposed assignment, the following leave(s) of absence will be approved and the
applicant will be released under the conditions checked below in order to accept a position under the Fulbright Teacher
Exchange Program.

With salary
Yes

Without salary

According to institutional/district procedures, we conducted a criminal background check of the applicant at the time of his/her
employment.

B. DISAPPROVAL
The above teacher/administrator is employed by our school or school system and will not be granted a leave of absence.

C. OFFICIAL SIGNATURE
Note: This form must be completed and signed by the official who is authorized to approve participation in the exchange, grant a leave of
absence, and approve the appropriate salary arrangements for the college, school or school system in which the applicant is
employed, e.g., President, Headmaster, Superintendent or District Official.
Name and Job Title of Chief Administrator or Authorized Official (President, Headmaster, Superintendent or District Official):

Name and Address of School or School System (include number, street, city, state, zip code, phone number and email address):

Signature of Chief Administrator or Authorized Official (President, Headmaster, Superintendent or District Official):
Print Name:

Title:

Signature:

Date (mm-dd-yyyy):

This form is subject to release, on written request, to the applicant. (Privacy Act of 1974, Freedom of Information Act)
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About The Fulbright Teacher Exchange Program
The purpose of the Fulbright Teacher Exchange Program is to help promote mutual understanding between the people of the
United States and the people of other countries through educational exchange. Teachers and administrators participating in the
program have the opportunity to live and work abroad by exchanging positions with educators from similar institutions in over twenty
countries. Teachers may also apply to attend summer seminars or special short programs.
Fulbright exchange teachers usually exchange positions with foreign teachers for an academic year. By living and working in the
cultures of their host countries, they gain an understanding and appreciation of the similarities and the differences between nations.
If your teacher is proposed for an exchange, you will have the opportunity to review the credentials of the foreign teacher and to
accept or reject the proposed exchange arrangement. In order for an exchange to take place it must be accepted by the U.S.
teacher, the U.S. administrators, and the foreign teacher, and the foreign administrators, and must be approved by the J. William
Fulbright Foreign Scholarship Board (FSB). At the time of this application your signature on the reverse administrative
approval form simply enables your teacher to be eligible for the program and indicates your willingness to consider a
Fulbright Teacher Exchange at your school/college.

The success of the Fulbright Teacher Exchange Program in increasing international understanding and properly representing the
educational system and other aspects of American life and culture depends greatly upon the exercise of judgment by school
administrators in approving their teachers'/administrators' participation in the program. It is important to the reputation of the program
and the American educational system, as well as that of the participating school, that an applicant be approved for participation only
if the approving official has no reservations about his or her character, reliability, and judges him or her to have superior
qualifications and to be an excellent representative of American education.

Most exchanges occur with both U.S. teachers and foreign teachers receiving their regular salaries from their home schools while
teaching and living abroad, though specific arrangements vary for each country. U.S. schools will not be asked to pay the salaries
of the foreign exchange teachers. Housing arrangements are the responsibility of the teachers involved.

Both the U.S. and the foreign teacher will be provided with a limited medical insurance policy by the U.S. government. However,
your teacher should continue his or her current coverage from your school, and we encourage you to consider including your
foreign teacher and any accompanying family members in your local group health plan.

Please return this form to:
Fulbright Teacher Exchange Program
600 Maryland Avenue, SW, Suite 320
Washington, DC 20024
Tel (202) 314-3520

PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Section 102 of the Mutual Educational and Cultural Exchange Act of 1961,
as amended (the Fulbright-Hays Act) (22 U.S.C. 2452).
PURPOSE: The information solicited on this form is necessary to evaluate a candidate's eligibility and suitability for participation in
the Fulbright Teacher Exchange Program, for general statistical use within the Department of State, and to direct program outreach
strategies in subsequent program cycles. Failure to provide the information requested on this form may result in non-selection.
ROUTINE USES: The information may be shared with overseas counterpart agencies of the Bureau of Educational and Cultural
Affairs or field personnel in selected countries to ensure matching with a foreign counterpart, and with local school authorities for their
concurrence on the exchange. The information provided may also be released to federal, state, local, or foreign government entities
for law enforcement purposes.

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IMMEDIATE SUPERVISOR REFERENCE FOR APPLICANT

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

IMPORTANT: The success of this program depends on the selection of educators whose qualifications give promise of outstanding success
under unusual circumstances abroad. Please see Fulbright Teacher Exchange Program description on the reverse of form.
ID#:09

1. Name of Applicant (last, first, middle):
2. Check the Applicant's professional qualifications and personal traits:
Item

Superior

Average

Above Average

Below Average

PROFESSIONAL QUALIFICATIONS
Knowledge of the subject field
Effectiveness with students of diverse levels of preparation
Ability to work with colleagues, including those with divergent views
Adherence to established administrative policies and procedures

PERSONAL TRAITS
Adaptability
Resourcefulness
Self-reliance
Initiative
3. Additional comments on the applicant's professional competence, experience, accomplishments, and personal qualities. Also indicate
any limitations. Use additional page if necessary.

4. Number of years you have known applicant:

5. Is the applicant a full-time teacher or administrator?

Yes

6. Please provide a general description of your teacher's school/college. Comment on how you feel the school, college, or district will
benefit from participating in the Fulbright Teacher Exchange Program. Use additional page if necessary.

7. Can the U.S. teacher's course load be altered for the foreign teacher ?

Yes

Please describe any special consideration that could be given to the incoming exchange teacher, (e.g., orientation, reduced teaching
load, extra preparation periods, special assignments teaching about home country culture, special support staff to assist exchange
teacher with instructional or related duties, other). Please continue on the reverse of this page, or use additional sheets.

Name and Job Title (include Dr., Mr., Mrs., Ms., Miss):

10. Name and Address of School (include number, street, city, state, zip code, phone number and email address):

11. Print Name:
Signature:

12. Title:

Date (mm-dd-yyyy):

This form is subject to release, on written request, to the applicant. (Privacy Act of 1974, Freedom of Information Act)
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Page A 13

Additional Space for Items 3, 6 and 8 (please use additional sheet if necessary):

Fulbright exchange teachers usually exchange positions with foreign teachers for an academic year. By living and working in the
cultures of their host countries, they gain an understanding and appreciation of the similarities and the differences between nations.
Visiting teachers share new perceptions with their students, and the returned Fulbright exchange teachers transmit an ongoing sense
of awareness about what is happening in that part of the world in which they have been living and teaching.

Please return this form to:
Fulbright Teacher Exchange Program
600 Maryland Avenue, SW, Suite 320
Washington, DC 20024
Tel (202) 314-3520

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REFERENCE FOR APPLICANT

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

1. Name of Applicant (last, first, middle):
2. Check the Applicant's professional qualifications and personal traits:
Item

Superior

Above Average

Average

Below Average

4. Professional relationship to the applicant:

5. Number of years you have known the applicant:

6. Name and Job Title (include Dr., Mr., Mrs., Ms., Miss):

7. Professional Address (include institution, number, street, city, state, zip code, phone number and email address):

9.
Print Name:

Title:

Signature:

Date (mm-dd-yyyy):

This form is subject to release, on written request, to the applicant. (Privacy Act of 1974, Freedom of Information Act)

DS-4502
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Page A 15

Fulbright exchange teachers usually exchange positions with foreign teachers for an academic year. By living and working in the
cultures of their host countries, they gain an understanding and appreciation of the similarities and the differences between nations.
Visiting teachers share new perceptions with their students, and the returned Fulbright exchange teachers transmit an ongoing
sense of awareness about what is happening in that part of the world in which they have been living and teaching.

Please return this form to:
Fulbright Teacher Exchange Program
600 Maryland Avenue, SW, Suite 320
Washington, DC 20024
Tel (202) 314-3520

PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Section 102 of the Mutual Educational and Cultural Exchange Act of 1961, as
amended (the Fulbright-Hays Act) (22 U.S.C. 2452).
PURPOSE: The information solicited on this form is necessary to evaluate a candidate's eligibility and suitability for participation in
the Fulbright Teacher Exchange Program, for general statistical use within the Department of State, and to direct program outreach
strategies in subsequent program cycles. Failure to provide the information requested on this form may result in non-selection.
ROUTINE USES: The information may be shared with overseas counterpart agencies of the Bureau of Educational and Cultural
Affairs or field personnel in selected countries to ensure matching with a foreign counterpart, and with local school authorities for
their concurrence on the exchange. The information provided may also be released to federal, state, local, or foreign government
entities for law enforcement purposes.

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Page A 16

REFERENCE FOR APPLICANT

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

1. Name of Applicant (last, first, middle):
2. Check the Applicant's professional qualifications and personal traits:
Item

Superior

Above Average

Average

Below Average

4. Professional relationship to the applicant:

5. Number of years you have known the applicant:

6. Name and Job Title (include Dr., Mr., Mrs., Ms., Miss):

7. Professional Address (include institution, number, street, city, state and zip code, phone number and email address):

9.
Print Name:

Title:

Signature:

Date (mm-dd-yyyy):

This form is subject to release, on written request, to the applicant. (Privacy Act of 1974, Freedom of Information Act)
DS-4502
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Page A 17

About The Fulbright Teacher Exchange Program

The purpose of the Fulbright Teacher Exchange Program is to help promote mutual understanding between the people of the United
States and the people of other countries through educational exchange. Teachers and administrators participating in the program have
the opportunity to live and work abroad by exchanging positions with educators from similar institutions in over twenty countries.
Teachers may also apply to attend summer seminars or special short programs.

Fulbright exchange teachers usually exchange positions with foreign teachers for an academic year. By living and working in the
cultures of their host countries, they gain an understanding and appreciation of the similarities and the differences between nations.
Visiting teachers share new perceptions with their students, and the returned Fulbright exchange teachers transmit an ongoing sense of
awareness about what is happening in that part of the world in which they have been living and teaching.

Please return this form to:
Fulbright Teacher Exchange Program
600 Maryland Avenue, SW, Suite 320
Washington, DC 20024
Tel (202) 314-3520

PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Section 102 of the Mutual Educational and Cultural Exchange Act of 1961, as
amended (the Fulbright-Hays Act) (22 U.S.C. 2452).
PURPOSE: The information solicited on this form is necessary to evaluate a candidate's eligibility and suitability for participation in
the Fulbright Teacher Exchange Program, for general statistical use within the Department of State, and to direct program outreach
strategies in subsequent program cycles. Failure to provide the information requested on this form may result in non-selection.
ROUTINE USES: The information may be shared with overseas counterpart agencies of the Bureau of Educational and Cultural
Affairs or field personnel in selected countries to ensure matching with a foreign counterpart, and with local school authorities for their
concurrence on the exchange. The information provided may also be released to federal, state, local, or foreign government entities
for law enforcement purposes.

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Fulbright Teacher Exchange 2009-2010
Program Information Questionnaire

*OMB Approved No. 1405-0114
Expiration Date: xx/xx/xxxx
Estimated Burden: 2 Hours

Please complete and return this form regardless of whether or not you decide to apply for the program. Completing this questionnaire is
voluntary. This form should be mailed separately from the application. No postage is necessary.
1.

Your State

Your teaching subject and level

How did you find out about the Fulbright Teacher Exchange Program ? (Please indicate the approximate date.) (mm-dd-yyyy)

Professional Journal or Magazine (name)
Conference
A Publication or Letter distributed by the Fulbright Teacher Exchange Program (please specify)

A former Fulbright Participant (name)
A Foreign Teacher presently on exchange in your school or community (name of teacher and school)

I am a former applicant to the Fulbright Teacher Exchange Program (year)
School or College Administrator
School Newsletter (name)
Newspaper Article (name)
Other
4.

When did you request the application (please give an approximate date) (mm-dd-yyyy)

When did you receive the application (please give an approximate date) (mm-dd-yyyy)

How did you receive the application ?
Fulbright

Conference

School or College Administrator

Colleague

Other

Have you decided to apply for the program this year ?
If not, why not ?

Are there countries, not presently in the program, that you are interested in exchanging in ? Please specify.

Do you have any further suggestions for future recruitment and advertising techniques ? Please specify.

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Agencies Administering Fulbright Programs
in Cooperation with the United States Department of State and
the J. William Fulbright Foreign Scholarship Board
U.S. Student Program

Institute of International Education (IIE)

Foreign Student Program (General information only)

809 United Nation Plaza
New York, N.Y. 10017
(212) 984-5330
www.iie.org

Foreign students from the Middle East and North Africa

America-Mideast Educational and Training Services Inc.
(AMIDEAST)
1730 M Street, NW, Suite 1100
Washington, D.C. 20036
(202) 776-9600
www.amideast.org

U.S. Scholar Program
Visiting Scholar Program

Council for International Exchange of Scholars (CIES)
3007 Tilden Street, NW, Suite 5L

Scholar-n-Residence Program
Senior Specialist Program
New Century Scholars Program

Washington, D.C. 20008-3009

Junior Faculty from Central and Latin America

LASPAU: Academic and Professional Program for the Americas
25 Mount Auburn Street

(202) 686-4000
www.cies.org

Cambridge, MA 02138-6095
(617) 495-5255
www.laspau.harvard.edu
Teacher Exchange Program

Graduate School, USDA
600 Maryland Avenue, SW Suite 320
Washington, D.C. 20024-2520
(202) 314-3520
[email protected]
www.fulbrightexchanges.org

Educational Partnership Program

United States Department of State

Hubert H. Humphrey Fellowship Program

Humphrey Fellowships & Institutional Linkages Branch
301 4th Street, SW, Room 349, SA-44
Washington, D.C. 20547
(202) 619-5289
http://exchanges.state.gov/education/hhh

Study of the United States Program

Fulbright Programs focusing on foreign language and
area studies

DS-4502

United States Department of State
Study of the United States Branch
301 4th Street, SW, Room 252, SA-44
Washington, D.C. 20547
(202) 619-4557
http://exchanges.state.gov/education/amstudy
United States Department of Education
International Education and Graduate Programs
1990 K Street, NW, 6th Floor
Washington, D.C. 20006-8521
(202) 502-7700
www.ed.gov/offices/HEP/iegps

Page A 21

File Type	application/pdf
File Title	DS4502.far
Author	manguerranc
File Modified	2008-09-25
File Created	2008-09-18