2022 Cochran Application

OMB Control No. 0551-New

Expiration Date: ##/##/####

COCHRAN FELLOWSHIP PROGRAM 2022

APPLICATION FORM

****** NOTE: PLEASE TYPE. APPLICATION AND ATTACHMENTS MUST BE IN ENGLISH. ******

COMPLETED APPLICATION SHOULD INCLUDE:

• 2 Letters of Recommendation

• 1 Passport Photograph

• 1 Photocopy of Passport Page

(front page only)

• Signed and Initialed Conditions of Training (page 8)

• Medical Clearance Documentation

(upon acceptance into the program)

• Signed Photo Consent Form (page 9)

I. PERSONAL INFORMATION:

Name:

Family Name/Surname Given Name

(Name must correspond exactly with passport or travel documents)

Date of Birth:

(Day / Month / Year) E.g. 03/March/1970

City of Birth:

Country of Birth:

Countries of Citizenship:

Country and Postal Code:

Have you ever applied for U.S. Residence: Yes No

Home Address:

Number, Street

City or Town

Country and Post Code

II. CURRENT EMPLOYMENT:

Title or Position

Organization/Company

Number, Street

City or Town

___________________

Gender: MALE FEMALE

Home Telephone

Personal Mobile Telephone

Personal Email Address

Dates of Current Employment:

From: To: Present

Work Telephone

Work Mobile Telephone

Work Email Address

Description of your place of employment and your duties and responsibilities:

III. PREVIOUS EMPLOYMENT:

A) Dates of Previous Employment:

From: To:

Title or Position

Organization/Company Supervisor's Name

Number, Street Supervisor's Telephone

City or Town Supervisor’s Email

Country and Postal Code Organization Telephone

Description of your place of employment and your duties and responsibilities:

B) Dates of Previous Employment:

From: To:

Title or Position

Organization/Company Supervisor's Name

Number, Street Supervisor's Telephone

City or Town Supervisor’s Email

Country and Postal Code Organization Telephone

Description of your place of employment and your duties and responsibilities:

IV. PROPOSED TRAINING PROGRAM:

1. What technical subjects, topics, courses and/or fields do you want to study?

(It is important to provide a detailed description of how this training will be useful to you and your industry. USDA will use this information to design your training program in the United States. You may use the back of this page if you need additional space for your response.)

2. U.S. Contacts Already Established:

(Please list the name, address, and telephone number of any US professionals in your field with whom you already have contact.)

Name Title Company Address Telephone Email

Name Title Company Address Telephone Email

Name Title Company Address Telephone Email

V. TRAINING BENEFITS:

How will your employer use the knowledge and skills you learned during your training when you return from the United States?

VI. SUPERVISOR’S RECOMMENDATION FOR APPLICANT'S TRAINING:

(Please have your supervisor complete the following questions. Provide an English translation, if necessary.)

A) What do you want the applicant to learn while in the United States for training?

B) How will the applicant's training be used by the organization/company upon his/her return?

Supervisor’s Name (Please Print)

Supervisor’s Signature

Title

Date

VII. ACADEMIC EDUCATION AND TRAINING EXPERIENCE:

A) Academic Education:

Name of Institution	Degree	Dates of Completion	Language of Instruction/ City and Country of Instruction

B) Training: (List additional training received in home country or other countries)

Training Name/Field of Study	Dates	Language of Instruction/ City and Country of Instruction

C) Awards, Honors, Scholarships Received, Publications, Professional Memberships:

VIII. NAME AND ADDRESS OF PERSON TO CONTACT IN CASE OF EMERGENCY:

Name Home Telephone

Relationship Mobile Telephone

Number, Street Email Address

City or Town

Country and Postal Code

IX. ATTACHMENTS:

Please include with your application the following attachments:

1.) 1 passport photograph

2.) 2 letters of recommendation

3. 1 photocopy of international passport page (front page only)

COCHRAN FELLOWSHIP PROGRAM

CONDITIONS OF TRAINING

Name of Applicant:

(FAMILY NAME/SURNAME, Given name, Other names)

Country:

If I am accepted to receive technical training under the U.S. Department of Agriculture (USDA) Cochran Fellowship Program, I agree to adhere to my arranged program, to devote my time and attention to my studies and/or practical training, and to conform to Cochran Fellowship Program regulations and procedures for the duration of my training program. I will adhere to the arrival and departure dates stated in the Official Call Forward Letter. I agree to arrive in the United States (City and State) as indicated in the Official Call Forward Letter and depart for my home country from the United States (City and State), also as indicated in the Official Call Forward Letter. Upon my return, I agree to provide feedback to training providers and FAS staff as requested. I will not seek extension of the period of my program but will return to my country without delay upon completion of my training acquired under this program. I also agree to conform to all laws of the United States.

Furthermore, I thoroughly understand the following requirements and policies of the Cochran Fellowship Program:

1. Dependents:

The Cochran Fellowship Program does not permit anyone to accompany or join a Fellow during their training program in the United States. 

2. Attendance of Fellows at Conferences and Meetings:

Attendance of fellows at conventions or meetings of professional, trade, or other associations is not permitted unless such attendance is a part of the Cochran Fellowship Program.

3. Conditions for Termination of Training Programs:

1. USDA reserves the right to terminate the training program of those Fellows who:

2. Change the course of study or depart the program without authorization from the USDA/Cochran Fellowship Program.

3. Fail to show sufficient interest or actively participate in their training program.

4. Have severe mental or physical health problems.

5. Conduct themselves in a manner prejudicial to the program or to the laws of the United States.

6. Marry during training without prior notification to USDA.

7. Have, in any way, falsified information on the application and/or supporting documents.

8. Are not compliant with the Two-Year Residence Requirement for DS-2019 SEVIS Program.

9. Have anyone to accompany or join them during their training program in the United States. 

4. Travel:

If selected, the applicant, their institution, or other sponsor assumes financial responsibility for air travel to and from their specified arrival/departure site. Fellows are not permitted to rent or drive vehicles during their Cochran Fellowship Program.

5. Financial Support:

The applicant is aware that the financial support provided by the Cochran Fellowship Program is for training fees, emergency medical insurance, domestic transportation, lodging and food only. The daily maintenance allowance is based on U.S. General Services Administration rates and is adequate for modest lodging and food.

In most cases, the Cochran Fellowship program does NOT cover the cost of international airfare.

Please initial here to indicate you understand this requirement.

If your organization or company is funding your international airfare, please complete the following question:

Do you have guaranteed/approved funding from your company or organization? Yes No

6. Health and Insurance:

   1. It is a requirement before arrival in the United States that every fellow has a physical examination and be determined to be in good health. Proof of medical fitness (a signed letter from a licensed medical doctor within 1 month of the program start date) is required before you will be allowed to travel to the United States as a Cochran Fellow. The insurance provided to the Fellow while in the United States will cover only EMERGENCY medical care and DOES NOT cover pre-existing conditions, prescriptions, dental or optical work. In addition, the Fellow may be responsible for paying the established deductible ($100.00 USD) for each occurrence. I understand that USDA and its training providers are not responsible for any costs related to medical care while in the United States.

7. Debts and Obligations:

   1. The Fellow will be responsible for all debts and financial obligations they may have incurred while in the United States.

8. Two-year Home-Country Physical Presence Requirement:

When you agree to participate in an Exchange Visitor Program, you will be subject to the two-year home-country physical presence (foreign residence) requirement if the following conditions exist: Government funded exchange program - The program in which the exchange visitor was participating was financed in whole or in part directly or indirectly by the U.S. government or the government of the exchange visitor's nationality or last residence. This requirement under immigration law is based on Section 212(e) of the Immigration and Nationality Act. This means you will be required to return to your home country for two years at the end of your exchange visitor program before you will be eligible to apply for:

1. An immigrant visa or permanent residence,

2. A nonimmigrant J visa as the fiancé of a U.S. citizen,

3. A nonimmigrant H visa as a temporary worker or trainee, or

4. A nonimmigrant L visa as an intracompany transferee, or

5. A nonimmigrant H or L visa as the spouse or minor child of a person who has been granted status in H or L nonimmigrant classification as a temporary worker or trainee or an intracompany transferee.

For additional information for this requirement, please visit: https://egov.ice.gov/sevishelp/programsponsoruser/two-year_home-country_physical_presence_requirement.htm

9. English Language Proficiency:

   1. All participants are required to be proficient in the oral and written usage of the English language.

Please initial here to indicate you understand this requirement.

Signature below indicates agreement to and understanding of the Conditions of Training.

Applicant Name (Print)

Applicant Signature Date

PHOTO CONSENT/RELEASE

I hereby consent to the royalty-free use by the United States Department of Agriculture (USDA) of photograph(s) taken of me by employees/representatives of the USDA Office of Communications, Photography Services Division, and of any reproduction of the photograph(s) in any form, in any media, for any purpose in connection with USDA, world-wide, free and clear of any claim whatsoever on my part.

I also consent to the use with the photograph(s) of my name and any comments I may have made at the time of the photograph(s), including the editing thereof.

Furthermore, I understand that this consent includes consent to USDA to use the photograph(s), with or without my name and any comments, for educational, promotional, and outreach purposes, and to use alone or in conjunction with other types of material, including use on the Internet and other means of public display.

I hereby release the United States, its officers, and employees from liability for any violation of any right I may have in connection with the foregoing use.

I hereby waive any right of inspection or approval of the photograph(s) or of the use that may be made of the photograph(s), my name, and my comment(s).

I am of legal age.

Applicant Signature Date

(Please Print)

Name Telephone

Address

Public Burden Statement. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The public reporting burden for this information collection is estimated to average 47 minutes per response, including the time for reviewing instructions, and completing and submitting the collection of information.

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