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TERMS OF GRANT CERTIFICATION
Application Form
| APPLICANT: | |||||
| Full Name (Last, First, Patronymic/Middle) [1]: | |||||
| Gender: | Male Female | Citizenship[2] | Russian Other | ||
| Email: | |||||
| Phone Number: | Work: | Home: | Mobile: | ||
| APPLICANT INSTITUTION: | ||||
| Institution Name: | ||||
| Institution Type: | University/academic | |||
| Complete Mailing Address: | ||||
| Institution Representative | Name: | Title: | ||
| Contact Information: | Email: | Tel.: | ||
| SIGNATURESScanned, dated and signed copies of this cover sheet are required for applicants | ||||
| Signature | Date | |||
| Institution Representative Signature | Date | |||
| APPLICANT INFORMATION: FAMILY | ||
| Marital status | ||
| Do you own a house or property? Please describe. | ||
| Do you have children? | ||
| Please list any family relations of yours currently residing in the U.S.: | Name: | Relationship: |
| By checking this box, you hereby certify your intent to return to Russia immediately upon NBEE program completion: | Signature_______________________Date _______________ |
| APPLICANT INFORMATION: TRAVEL | ||||||
| Travel Information: | Do you have a valid passport to travel to the U.S.? | Yes | No | |||
| List Previous International Travel: Indicate places, dates, and reasons (add rows, if necessary): | ||||||
| Country | Dates | Sponsor | Reason/Purpose | |||
| List Any Contacts you have in the U.S.?[3] Add rows, if necessary | ||||||
| Name | Relationship | |||||
| Do you have an open U.S. Immigration Visa Request? | Yes | No | ||||
| Have you previously attended an event sponsored by the U.S. government or received a U.S. research grant? | ||||||
| Please list event(s) attended and/or grant(s) received (add rows if necessary): | ||||||
| Event or Grant | Dates | Funding Amount | Purpose | |||
| APPLICANT INFORMATION: EDUCATION | |||||||||
| A. List all university education, beginning with most recent | |||||||||
| Dates | Institute University | Major Field of Study | Degree / Date received | ||||||
| B. Indicate any academic or professional honors or awards you have received (max 350 words) Please include titles and dates. | |||||||||
| C. List any books, articles or papers that you have published. Please list article and journal titles and dates. | |||||||||
| D. List professional societies, associations, or other organizations of which you are a member, past or present. Please include dates of membership. | |||||||||
| E. Please describe any research you have completed or in which you are currently involved. Include the name of the laboratory/institution. | |||||||||
| F. Please include any leadership positions you have held or currently hold along with the institution name and the dates. | |||||||||
| G. Language Skills (Please rate yourself Excellent, Good, Fair, Poor for all languages with which you are familiar.) | |||||||||
| Language | Reading | Writing | Speaking | Comprehension | |||||
| 1. English | |||||||||
| Have you ever taken a TOEFL exam[4]? | Yes | No | |||||||
| APPLICANT INFORMATION: EMPLOYMENT EXPERIENCE | |||||||||
| A. Current Place of Employment, please provide complete information about the institution, department, etc. | |||||||||
| D. Duties and Responsibilities | |||||||||
| B. Employment History, beginning with most recent | |||||||||
| Dates | Employer | City | Position | Responsibilities | |||||
| C. Professional References (Please list your current supervisor and two other professional references (name, email, and phone number are required)[5] | |||||||||
| Name | Organization, title, contact information (email, phone number) | Relationship | |||||||
Statement of Purpose
| Brief summary of past and current research |
| Goals and reason for travel (Please state at least three clear goals for your NBEE participation) |
| Proposed activities and events during the trip (Please propose at least two specific events scheduled for September 2016 or later. One of these events MUST be an international scientific conference where you intend to present on your research. ) |
| Please describe the anticipated results of your proposed activities, and how new knowledge and experience will be used. |
| What do you think makes you a good candidate for this program? |
| Please write a brief action plan for how you will take what you gain through this program and apply it to your research in Russia. |
APPLICATION CHECKLIST
€ Application Form
€ All fields are completed page each
€ Signed by an institution representative (an approval for the applicant to participate in the program for 10-14 days during the program dates, if awarded)
€ CV
€ Should not exceed four pages in length
€ Highlights major research accomplishments to date including all publications
€ Highlights employment and academic experience
€ Membership in any societies
€ Letter of Support (LOS)
€ A Letter of Support (LOS) from a supervisor highlights the position and expertise of the applicant.
€ Scanned Copy of the completed, dated, and signed Personal Data Consent Form
SUBMISSION INSTRUCTIONS
The following documents should be submitted to CRDF Global Moscow office as SEPARATE files
· Application Documents – all required documents submitted as email attachments, either MS Word or Adobe PDF
· Personal Data Consent Form (completed, dated, and signed) - scanned copy by email together with application documents, and a hard copy (originals) by mail.
TERMS OF GRANT CERTIFICATION
IT IS VERY IMPORTANT THAT ALL APPLICANTS READ AND UNDERSTAND THE TERMS OF THIS GRANT.
I testify that the information submitted in this application is complete and accurate. I understand that providing false information on this application or during the interview may disqualify me from participation in the Academic Network Building, Education and Exposure Program, or if I am selected, dismissal from the program. If selected, I agree to comply with all regulations of the Academic Network Building, Education and Exposure Program and all local and national laws of the U.S. Regulations of the Academic Network Building Program including, but are not limited to: program policies, selected conference rules and requirements, CRDF Global expense reimbursement rules and requirements and regulations of the labs hosting site visits.
All applicants accepted into the Academic Network Building, Education and Exposure Program will receive the following support from CRDF Global:
1. Letter of support for visa application and visa fees
2. Round-trip, economy-class airfare from home city in Russia to the U.S.
3. Ground transportation to/from airports of arrival and departure and, when necessary, ground transportation to/from hotel and conference and/or site visits
4. Hotel lodging within reasonable proximity of the U.S. conference and site visits and according to U.S. government rates
5. Stipend for meals and incidental expenses according to U.S. government rates
6. Emergency Medical Insurance during dates of travel
By participating in the Academic Network Building Program:
I understand and acknowledge that CRDF Global reserves the right to restrict the participation of any individual or institution in its programs. CRDF Global complies with all U.S. laws and regulations pertaining to export control and the participation of foreign nationals or institutions in its activities. It is the policy of CRDF Global not to conduct any transactions with U.S. restricted entities without appropriate authorization from the U.S. Government.
I understand and acknowledge that CRDF Global support is limited to the financial transactions itemized above and is contingent upon my successful participation in the Professional Network Building Program. I understand that if I do not complete the travel awarded for this grant, I will be required to return a pro-rated stipend amount to CRDF Global and may be required to reimburse CRDF Global for any additional travel expenses incurred as a result of my early departure.
I understand and acknowledge that CRDF Global will obtain lodging on my behalf and will make payment directly to the provider, however I am responsible for ensuring the proper use and care of any lodging facilitates. I understand that I may be considered personally liable for any damages that occur at my lodging facilities.
I understand and acknowledge that CRDF Global will obtain emergency medical insurance on my behalf and will make payment directly to the provider, however this insurance is to be utilized only for emergency situations and not for routine medical care or treatment, including for any pre-existing medical or dental condition. I further understand that I may be required to pay all deductibles and other health-related expenses not covered by the insurance.
I understand and acknowledge that the U.S. visa obtained in connection with my Academic Network Building Program is valid only for temporary non-degree-seeking professional travel and is not valid for employment in the U.S. I understand that returning to Russia at the end of the program is a mandatory condition of my participation in the Academic Network Building Program and I declare my intent to comply. I understand that traveling to cities in the U.S. that are not part of the Academic Network Building Program, as well as travel outside the U.S., is strictly prohibited under the terms of my U.S. visa and will result in immediate dismissal from the program. I understand that this program prohibits spouse and/or children to accompany program participants to the U.S.
(Signature) (Date)
Date: 2016-04-22; view: 837
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