2022.SEB.Application_20220803

OMB Control No. 0551-New

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

Fellowship and Exchange Program Application

Application form and all attachments must be typed in English

This document serves as a universal application for the Borlaug Fellowship Program, Scientific Exchanges Program, and Faculty Exchange Program. Prior to beginning this application, review the qualifications and eligibility for each program and select which program is most suited to your research interests. See program announcements for the Fellowship Program’s focus area by country.

All sections of the application must be completed according to the fellowship program for which you are applying. See below for requirements by program. Please include a copy of your passport with your application.

Table of Contents

General Information

1. Personal Information

2. Proposed Topic Summary

3. Education

4. Technical / Professional Training or Courses

5. Language Skills

6. Current Employment

7. Previous Employment

8. Professional Contacts

9. Awards, Honors, Scholarships

10. Previous FAS Fellowships

11. Professional Publications

12. Research Proposal

13. Research Action Plan

14. Approval of Home Institution

15. Faculty Exchange Program Additional Information

Professional Reference Letters

Conditions of Training

Applicant Certification

Photo Consent/Release

Application Requirements by Program

Please indicate the program most suited to your interests and eligibility.

Complete all necessary sections of the application according to the outline below.

Borlaug Fellowship Program

☐Sections I-XIV

☐Professional Reference (2)

☐Conditions of Training

☐Applicant Certification

☐Photo Consent/Release

☐Passport Copy

Scientific Exchanges Program

☐Sections I-XIV

☐Professional Reference (2)

☐Conditions of Training

☐Applicant Certification

☐Photo Consent/Release

☐Passport Copy

Faculty Exchange Program

☐Sections I-XI

☐Section XV

☐Teaching Experience

☐Department Head Questionnaire

☐University Letter of Commitment

☐Professional Reference (2)

☐Conditions of Training

☐Applicant Certification

☐Photo Consent/Release

☐Passport Copy

General Information

1. Personal Information

Last Name (Surname)	Click or tap here to enter text.
First Name	Click or tap here to enter text.
Middle Name(s)	Click or tap here to enter text.
Nationality	Click or tap here to enter text.
Gender	Click or tap here to enter text.
Home Mailing Address	Click or tap here to enter text.
Personal Email Address	Click or tap here to enter text.
Work Email Address	Click or tap here to enter text.
Work Phone (Include country / local area codes)	Click or tap here to enter text.
Home/Mobile Phone (Include country / local area codes)	Click or tap here to enter text.
Date of Birth	Click or tap here to enter text.
Country of Birth	Click or tap here to enter text.
Country Issuing Passport	Click or tap here to enter text.
Emergency Contact Name	Click or tap here to enter text.
Emergency Contact Phone (Include country / local area codes)	Click or tap here to enter text.
Emergency Contact Email	Click or tap here to enter text.
Countries of citizenship	Click or tap here to enter text.
If yes, please indicate which country or countries:	Click or tap here to enter text.

2. Proposed Topic Summary

In one sentence, please summarize your proposed research topic. You will have an opportunity to expand on your proposal details in Sections XII and XIII.

Click or tap here to enter text.

3. Education

Please list each college or university you have been enrolled in, beginning with the most recent.

Name of Institution and Country	Major Field of Study	Dates Attended (MM/YY-MM/YY)	Degree Earned	Date Completed (MM/YY)
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

4. Technical / Professional Training or Courses

Please list each relevant technical / professional training or courses you have completed, beginning with the most recent.

Name of Training or Course	Dates Attended (MM/YY-MM/YY)	Language of Instruction	Country of Instruction
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

5. Language Skills

Language (ex. English)	Reading	Writing	Speaking
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.

6. Current Employment

Organization or Company Name / Department	Click or tap here to enter text.
Mailing Address	Click or tap here to enter text.
Telephone Number	Click or tap here to enter text.
Web Site	Click or tap here to enter text.
Your Position Title	Click or tap here to enter text.
Supervisor’s Name / Position Title / Department	Click or tap here to enter text.
Supervisor’s E-mail Address	Click or tap here to enter text.
Supervisor’s Telephone Number	Click or tap here to enter text.
Duties: Please concisely describe your current job-related responsibilities and accomplishments	Click or tap here to enter text.
Dates of Employment	Click or tap here to enter text.

6. Previous Employment

Please indicate the number of positions you have had in the past 10 years:

Please list those positions below, beginning with the most recent:

Previous Job #1

Organization or Company Name / Department	Click or tap here to enter text.
Mailing Address	Click or tap here to enter text.
Telephone Number	Click or tap here to enter text.
Web Site	Click or tap here to enter text.
Your Position Title	Click or tap here to enter text.
Supervisor’s Name / Position Title / Department	Click or tap here to enter text.
Supervisor’s E-mail Address	Click or tap here to enter text.
Supervisor’s Telephone Number	Click or tap here to enter text.
Duties: Please concisely describe your previous job-related responsibilities and accomplishments	Click or tap here to enter text.
Dates of Employment	Click or tap here to enter text.
Reason for leaving	Click or tap here to enter text.

Previous Job #2

Organization or Company Name / Department	Click or tap here to enter text.
Mailing Address	Click or tap here to enter text.
Telephone Number	Click or tap here to enter text.
Web Site	Click or tap here to enter text.
Your Position Title	Click or tap here to enter text.
Supervisor’s Name / Position Title / Department	Click or tap here to enter text.
Supervisor’s E-mail Address	Click or tap here to enter text.
Supervisor’s Telephone Number	Click or tap here to enter text.
Duties: Please concisely describe your previous job-related responsibilities and accomplishments	Click or tap here to enter text.
Dates of Employment	Click or tap here to enter text.
Reason for leaving	Click or tap here to enter text.

6. Previous FAS Fellowship or Exchange Program

Please list any FAS-funded Fellowship or Exchange Program in which you have previously participated.

Fellowship or Exchange Program	Project Title	Description	Dates Participated
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

6. Professional Contacts in the United States

Please list any professional contacts you have in the United States.

Name	University/Organization	Email Address	Phone Number
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

6. Awards, Honors, Scholarships

Award Type / Title	Description	Date Received	Awarding Institution
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

6. Professional Publications

Beginning with the most recent publication, please list your professional publications below.

Journal Articles:

Click or tap here to enter text.

Conference Proceedings (Selected):

Click or tap here to enter text.

6. Research Proposal

Please answer the following questions in the space provided.

1. Identify your specific research objective(s).

Click or tap here to enter text.

2. Provide background information on your research, using terms someone unfamiliar with your scientific field will understand.

Click or tap here to enter text.

3. Describe what you hope to accomplish during your fellowship or exchange program.

Click or tap here to enter text.

4. How do your research interests and scientific background relate to the goals of your proposal?

Click or tap here to enter text.

5. How will working with a mentor in the United States help you to achieve your research goals?

Click or tap here to enter text.

6. How will this fellowship or exchange program contribute to enhanced agricultural productivity, economic development, and food security in your country?

Click or tap here to enter text.

7. Describe previous leadership and communication experience, especially in relation to policy and procedure amongst peers, decision-makers, policy developers, and the public.

Click or tap here to enter text.

8. What role will you have in policy change in relation to your research?

Click or tap here to enter text.

9. Are you currently involved in any committees (e.g., advisory, curriculum reform, policy, university, private institutions, or ministry committees)?

Click or tap here to enter text.

Borlaug Fellowship Program and Scientific Exchanges Program Applicants Only

6. Research Action Plan

Assuming a 12-week research program, provide a weekly plan of proposed research activities and planned outcomes to be accomplished. Your research plan should support your research goals and objectives. We recognize that this plan may change but encourage you to be as specific as possible. Note any special materials and/or requirements needed to support your research. Provide a weekly list of activities that links to your proposal's goals and objectives. (1000-word limit)

Click or tap here to enter text.

Borlaug Fellowship Program and Scientific Exchanges Program Applicants Only

6. Approval of Home Institution

I certify that Click or tap here to enter text.is a staff member at Click or tap here to enter text. and is under my supervision. I agree to his/her application to the and understand that, if selected, the candidate must be available to spend up to 12 weeks in the United States. I also understand that he/she may participate in a follow-up activity in his/her country in roughly 6-12 months following the completing of the training, if applicable.

USDA’s Borlaug Fellowship Program and the Scientific Exchanges Program promotes food security and economic growth in eligible countries by educating a new generation of agricultural scientists, increasing scientific knowledge and collaborative research to improve agricultural productivity, and extending that knowledge to users and intermediaries in the marketplace. Applicants are eligible to participate if currently employed by a university, government, research institution and/or other institution with the intent to continue working in their home country for a minimum of two years following the return from the United States.

I anticipate that this applicant will be employed by my institution and working for at least two years following the completion of his/her Fellowship Program.

Click or tap here to enter text. Click or tap here to enter text.

Name of Authorized Institutional Representative Position Title

Signature of Authorized Institutional Representative Date

Faculty Exchange Program Applicants Only

6. Faculty Exchange Program Additional Information

USDA’s Faculty Exchange Program assists developing countries in improving their university agricultural education, research, and extension programs by providing a one semester training program at U.S. Land Grant Agricultural Universities. Participants better their technical knowledge in their subject area, learn new teaching methods through class observation, and new research methods through experience in the lab, short courses, and/or one-on-one instruction. Please answer these additional questions about teaching experience below to address the agricultural education experience requirements.

Teaching Experience

1. What is your agriculture and life science teaching experience? (Describe any courses and adult education programs)

Click or tap here to enter text.

2. What agriculture and life science courses or adult education programs do you expect to teach in the future?

Click or tap here to enter text.

3. What two agriculture and life science courses do you wish to revise or create during the program?

Click or tap here to enter text.

4. Regarding curriculum or teaching, what specifically would you like to focus upon while in the United States?

Click or tap here to enter text.

Faculty Exchange Program Applicants Only

Department Head Questionnaire

Dear Department Head:

1. What are the professional strengths of this applicant?

Click or tap here to enter text.

2. How would this applicant’s participation be advantageous to your department?

Click or tap here to enter text.

3. Within the identified topics, what elements do you wish the applicant to focus on while they are in the United States?

Click or tap here to enter text.

4. What aspects of curricula development do you want the applicant to focus upon while they are in the United States?

Click or tap here to enter text.

Click or tap here to enter text. Click or tap here to enter text.

Name of Department Head Position Title

Signature of Department Head Date

Faculty Exchange Program Applicants Only

Approval of Home Institution

Enter University Name here.

If selected by the United States Department of Agriculture, the university administrators who sign below commit themselves to releasing Click or tap here to enter text. to travel to the United States to participate in the Faculty Exchange Program. Participation in the program requires the applicant to be available to spend one full semester in the United States and participate in a follow-up activity in his/her country about 3-9 months after the conclusion of the U.S.-based program.

The university administration authorizes the participant to bring copies of the university's curricula, course outlines, and teaching materials to the United States to be used by the participant for review, study, and comparison.

The university understands and accepts that the participant will develop proposals and suggest changes that they believe will improve this university's curricula, courses, and teaching methods.

The university administration agrees to consider in good faith proposals for change and to create opportunities for returning participants to share these ideas with other instructors at the university.

Click or tap here to enter text. Click or tap here to enter text.

Name of President or Dean Position Title

Signature of President or Dean Date

Click or tap here to enter text. Click or tap here to enter text.

Name of Department Head Position Title

Signature of Department Head Date

All Fellowship and Exchange Programs

Professional Contact Reference Letter

Please respond to the following questions in the space provided.

1. What is the applicant’s relationship to you? How many years have you known the applicant and in what capacity?

Click or tap here to enter text.

2. What are the professional strengths of the applicant? Where are the applicant’s opportunities to improve? How will this program help the applicant solidify strengths and achieve improvements?

Click or tap here to enter text.

3. Please provide examples of the leadership and communication skills of the applicant.

Click or tap here to enter text.

4. Describe the applicant’s willingness and ability to implement change amongst peers, policy developers, and the public.

Click or tap here to enter text.

5. How will participation in this fellowship or exchange program assist the applicant in achieving enhanced agricultural productivity in their country of representation?

Click or tap here to enter text.

Click or tap here to enter text. Click or tap here to enter text.

Name of Reference Position Title

Signature of Reference Date

All Fellowship and Exchange Programs

Professional Contact Reference Letter

Please respond to the following questions in the space provided.

1. What is the applicant’s relationship to you? How many years have you known the applicant and in what capacity?

Click or tap here to enter text.

2. What are the professional strengths and weaknesses of the applicant? How will this program help the applicant solidify strengths and improve weaknesses?

Click or tap here to enter text.

3. Please provide examples of the leadership and communication skills of the applicant.

Click or tap here to enter text.

4. Describe the applicant’s willingness and ability to implement change amongst peers, policy developers, and the public.

Click or tap here to enter text.

5. How will participation in this fellowship or exchange program assist the applicant in achieving enhanced agricultural productivity in their country of representation?

Click or tap here to enter text.

Click or tap here to enter text. Click or tap here to enter text.

Name of Reference Position Title

Signature of Reference Date

All Fellowship and Exchange Programs

Conditions of Training

Full Name of Applicant: Click or tap here to enter text.

If I am accepted to receive technical training under a U.S. Department of Agriculture (USDA) Fellowship or Exchange Program, I agree to adhere to my arranged program, to devote my time and attention to my research and/or practical training, and to conform to the USDA Fellowship or Exchange Program regulations and procedures for the duration of my fellowship or exchange program. I will not seek extension of the period of my program, and I will return to my country immediately upon completion of my program. I understand that I must fulfill the two-year home residency requirement of the J-1 visa. I agree to conform to all laws of the United States.

Furthermore, I certify that I understand and agree with the following policies of the Fellowship or Exchange Programs:

Dependents:

The Scientific Exchanges Branch of FAS Fellowship Programs Division does not permit anyone to accompany or join a Fellow during their training program in the United States.

Conditions for Termination of Research Programs:

USDA reserves the right to terminate the research program of those participants who:

A. Change the course of study without authorization from USDA.

B. Fail to show sufficient interest in or to effectively pursue their research program.

C. Fail to notify USDA of significant medical issues that could impact program.

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

E. Fail to disclose plans to marry or extend stay in the United States.

F. Obtain employment in the United States without prior notification to USDA.

G. Falsify information on the application and/or supporting documents in any way.

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

Financial Support:

The applicant is aware that the financial support provided by the Fellowship or Exchange Program is for travel, training fees, emergency medical insurance, lodging, and food only. The daily maintenance allowance is adequate for meals and incidental expenses, and it will be the only direct financial support provided to the Fellow.

Health and Insurance:

Before arriving in the United States, each participant is required to have a physical examination to determine that the participant is in good health. Proof of medical fitness (a signed letter from a licensed medical doctor within 2 months of the program start date) is required before you will be allowed to travel to the United States as a participant.

The insurance provided to the participant while in the United States will cover only emergency medical care and does not cover treatment of pre-existing conditions, prescriptions, dental, or optical treatment. Additionally, the participant must pay the first $100.00 USD of the total cost in medical expenses for each occurrence. By signing below, the participant certifies agreement to and understanding that USDA and its training providers are not responsible for any costs related to medical care.

Debts and Obligations:

The participant will be responsible for all debts and financial obligations incurred while in the United States.

I understand and agree to the above terms and conditions.

Click or tap here to enter text.

Name of Applicant

Signature of Applicant Date

All Fellowship and Exchange Programs

Applicant Certification

Signature indicates:

1. All information provided on this application form is true to the best of my knowledge. 

2. I understand that any willful misstatement may lead to disqualification and/or revocation of the fellowship or exchange.

3. I have no known, established, and/or expected business, employment, or other commitments that would prevent me from completing the fellowship or exchange if I am selected. 

Click or tap here to enter text.

Name of Applicant

Signature of Applicant Date

All Fellowship and Exchange Programs

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 Click or tap here to enter text. Telephone Click or tap here to enter text.

Address Click or tap here to enter text.

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 300 minutes per response, including the time for reviewing instructions, and completing and submitting the collection of information.

Page 2 of 19