Form DS-4297 FLO Professional Development Fellowship (PDF) Applicatio

OMB APPROVAL NO. 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX

U.S. Department of State

FLO Professional Development Fellowship (PDF) Application Form

By submitting this application, if selected for funding, I consent to the publication of my name by the Department as a recipient of a FLO Professional
Development Fellowship and to quote my comments about my experience in relevant publications.

Initial Here
Please read carefully and follow the instructions linked below. Applications that are late, incomplete, or contain ineligible expenses will not
be considered.
PDF Form Instructions
SECTION I: PERSONAL DATA
Last Name

First Name

Email - Personal

Title (Optional)
Email - Work (Official - Optional)

Check one:
Eligible Family Member Spouse

Member of Household Partner

Check all that apply:
First-time fellowship applicant

Prior fellowship applicant

Prior fellowship recipient (Select all applicable fellowship period(s)):
If you were a prior recipient, how did you use your PDF? (maximum 250 characters)

Employee Sponsor Last Name

Employee Sponsor First Name

Employee Sponsor Email - Work (Official)

Employee Sponsor Agency

Employee Sponsor Agency "Other"

Employee Sponsor Post(s) of Assignment during PDF Period

Dates of Assignment during PDF Period (MM/YYYY)

to
Is your spouse assigned to an unaccompanied tour (UT) during the PDF period?
Yes
DS-4297
11-2017

Where will you reside overseas during PDF period?
Page 1 of 4

SECTION II: PROPOSAL DESCRIPTION
A. Project Type
Please select one (For more than one select "Other")

B. Proposal Synopsis
Include only project activities that take place during the fellowship period (maximum 400 characters)

C. Background
Summary of your professional background (maximum 1700 characters)

Current challenges in pursuing career goals (maximum 1700 characters)

DS-4297

Page 2 of 4

SECTION III: DETAILED DESCRIPTION OF PROPOSED PROJECT
Include only project activities that take place during the fellowship period. Include links for activities and costs in the chart below your
description. (maximum 3000 characters total)

Name of Provider

DS-4297

Link to Project Activity

Link to Cost

Page 3 of 4

SECTION IV: BUDGET
Include only eligible project expenses for activities that occur during the fellowship period.
Please see instructions for eligible expenses.
1. Itemized breakdown of allowable reimbursable project expenses:

Total Reimbursable Project Expenses
2. Calculate minimum amount of Applicant Responsibility and Requested Fellowship Amount:
Total Reimbursable Project Expenses (from #1. above)

A

25% Applicant Responsibility: A x 25%

B

A-B

C

Enter Requested Fellowship Amount*

D

Remaining Additional Self-Funded Costs (if any) C - D

E

* Maximum reimbursable PDF fellowship amount is $2,500 and minimum is $1,000.

SECTION V: COMPLETION
Future plans if offered fellowship (maximum 500_characters):

**Please save your application as LastNameFirstInitial (ie. Jane Doe = DoeJ.pdf) and email to the address listed in the

INSTRUCTIONS .

**Applications are due to FLO no later than the date indicated in the instructions. Applications that are late, incomplete, or contain ineligible
expenses will not be considered.
DS-4297

Page 4 of 4