Form DS-7001 Edmund Muskie Graduate Fellowship Application

U.S. Department of State

OMB APPROVAL NO. 1405-0138
EXPIRATION DATE 11/30/2011
ESTIMATED BURDEN: 45 MINUTES*

PARTICIPANT APPLICATION

2011-2012 EDMUND S. MUSKIE GRADUATE FELLOWSHIP PROGRAM

1. Name (As Written on Official Documents)
(Family Name)

(Middle Name)

(First Name)

2. Country or Countries of Citizenship
3. Country of Legal Residence
4. Place of Birth
(Country)

(City or Town)

5. Date of Birth
(Month)

6. Gender

Male

Female

7. Marital Status

Single

Married

(Day)

(Year)

Citizenship(s) of Spouse (If Applicable)

8. In order to respond to required U.S. Government inquiries, please check the box below, on a voluntary basis,
if you have the following disabilities:
Hearing Impairment

Speech Impairment

Learning Disorder

Other (Specify)

Visual Impairment (Legally Blind)

Orthopedic Impairment

9. Current Contact Information
Address Type:

Dormitory

Permanent Residence

Street/Building Number

Apartment

City

Postal Index

Region

Country

Telephone

(

Fax

)

Cell Phone (If Applicable)

Temporary Residence (Other Than Dormitory)

(

(

Email

)

)

10. Permanent Home Address (If Different from Current)
Street/Building Number

Apartment

City

Postal Index

Region

Country

Telephone

(

)

Cell Phone (If Applicable)

Fax
(

(

)

Email

)

Paperwork Reduction Act Statement:
The information gathered is used by the U.S. Department of State's Bureau of Educational and Cultural Affairs (ECA) to inform program design,
management, and funding. The information collection activity involved with the program is conducted pursuant to the mandate given to the U.S.
Department of State under the terms and conditions of the Mutual Educational and Cultural Exchange Act of 1961, Public Law 87-256.
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on
the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department
of State, Washington, DC 20522-2202.
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11- 2010

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11. Work Address (If Applicable)
Name of Business
Title/Position
Street
City

Postal Index

Country

Telephone

(

)

Fax

(

)

12. Educational Background. In the table below, please list all universities, institutes, and special academic programs you have attended or
are currently attending, with the most recent listed first. Transliterate directly from your native language into English spelling all words pertaining
to your education. Do not use American equivalents unless you hold a degree from a U.S. academic institution.

Example
Institution and City

Department

Dates (Month-Year)

Type of Degree

Date Degree Received
or Expected

Moscow State University,
Moscow

Department of
Journalism

August 1990 May 1995

Diploma

May 1995

Institution and City

Department

Dates (Month-Year)

Type of Degree

Date Degree Received
or Expected

13. Testing. If you have not taken the Test of English as a Foreign Language (TOEFL), Graduate Records Examinations (GRE), or the Graduate
Management Admission Test (GMAT) and are selected as semi-finalist, you may be required to take the TOEFL and GRE or GMAT (business
administration applicants) exams. The cost of these examinations will be covered by this program.
If you have previously taken any of the above-mentioned examinations, please give your score and the date and place where you took the
examination. Attach a copy of your score report to the application if available. If selected, you may be required to submit official test results via
ETS directly to the programming agency.

TOEFL Score

Date (mm-dd-yyyy)

Location

GRE Score

Date (mm-dd-yyyy)

Location

GMAT Score

Date (mm-dd-yyyy)

Location

I have not taken the TOEFL, GRE, GMAT examination.

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14. University Courses. List below, in English, all the university courses you have taken, and the grades you received. First-year students
should list their current university courses followed by their 11th form courses and final grades.
Attach additional pages if necessary. Describe the grading system used (example: "5"= excellent to "1"=failing, "A"= excellent to "F"= failing):
Subject/Course (Class Title)

Academic Years (for example, 2004-2005)

Grade

15. Native Language Contact Information
Native Language is

.

During the selection process, it may be necessary for one of our offices to contact you. To assist our offices in maintaining accurate records,
please complete the following section in your native language.

Name
(Family Name)

(First Name)

Street/Building Number

(Middle Name)
Apartment

City

Postal Index

Country

Region

Please complete the following information in your native language with either your current academic institution information or employer
information, whichever is currently applicable:
Current Academic Institution/Employer
Department/Position
Dean or Academic Advisor/Supervisor Name
Dean or Advisor Telephone
Emergency Contact Name

(

)
Relationship

Emergency Contact Address
Emergency Contact Phone/Fax/Email

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16. Preferred Length of Program (Please check the program length that you prefer. NOTE: approximately 40% of all finalists will be
placed in one-year programs, including non-degree programs. You may be placed in a one-year program even if you do not specifically
check this option.)
One-Year

Two-Year (including 15-16 month programs)

17. Proposed Field of Study (Check one):
NOTE: CITIZENS OF RUSSIA AND UKRAINE ARE ELIGIBLE ONLY FOR THE FOLLOWING FIELDS OF STUDY: BUSINESS
ADMINISTRATION, ECONOMICS, LAW, PUBLIC ADMINISTRATION, AND PUBLIC POLICY.
Business Administration

Law

Economics

Library and Information Science

Education

Public Administration

Environmental Management

Public Health

International Affairs

Public Policy

Journalism and Mass Communications

18. How did you first learn about this program?
Please check only one:
Academic Advisor

IATP site

Program Alumni

Conference Booth

Internet

Radio

Educational Advising Center

Programming agency

Television

Electronic listserv

Lecture/Presentation

University faculty/staff

Friend/Colleague

Newspaper/Advertisement

U.S. Embassy

Other (Please Specify):

19. Are you applying to any other sponsored educational exchange program for the upcoming academic year?

Yes

No

Yes

No

If yes, please specify
Name of Sponsoring Organization

20. Previous VISA Information
a. Have you previously traveled on a U.S. Government-sponsored or other U.S. exchange program?
If yes, please complete the following:
Year(s)

Name

Location in the U.S.
(City)

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(State)

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20. Previous VISA Information (continued)
b. Have you ever received a U.S. J-1 Visa?

Yes

No

If yes, list dates showing exact duration of stay in the United States on a J-1 visa (month-day-year - month-day-year).

c. Have you ever received a U.S. F-1 Visa?

Yes

No

If yes, list dates showing exact duration of stay in the United States on a F-1 visa (month-day-year - month-day-year).

d. Have you been in the U.S. for any other reason?

Yes

No

If yes, please list the duration of stay in the United States, except for visits to the United States as a tourist (month-day-year - month-day-year).

21. Extra-Curricular Activities. Please list all volunteer positions, work experience, awards, and leadership positions you have
held within the past four years.

22. How long did it take you to answer this application?
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minutes.
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